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TRICARE

®

For Life Handbook

TR

ICA

RE F

or

Life

Wis

consi

n P

hys

icia

ns

Serv

ice

ww

w.T

RIC

AR

E4u.c

om

1-8

66-7

73-0

404

TR

ICA

RE N

ort

h R

egi

on

Heal

th N

et

Federa

l Se

rvic

es,

LLC

ww

w.h

nfs

.com

1-877-

TR

ICA

RE (

1-877-

874

-2273)

TR

ICA

RE S

outh

Regi

on

Hum

ana

Mili

tary

, a

div

isio

n o

f

Hum

ana

Gove

rnm

ent

Busi

ness

Hum

ana-

Mili

tary

.com

1-800-4

44-5

445

TR

ICA

RE W

est

Regi

on

Unit

edH

eal

thca

re M

ilita

ry &

Vete

rans

ww

w.u

hcm

ilita

ryw

est

.com

1-877-

988-W

EST

(1-

877-

988-9

378)

ww

w.t

rica

re.m

il

HA6551BET11123

TRICARE Expectations for Beneficiaries

Acc

ord

ing

to t

he D

epar

tment

of D

efe

nse

(D

oD

), a

s a

TR

ICA

RE b

enefici

ary,

you

should

expect

to h

ave

the

follo

win

g ab

ilities

and s

upport

:

You s

hould

expect

to r

ece

ive a

ccura

te, eas

y-to

-unders

tand info

rmat

ion fro

m w

ritt

en

mat

eri

als,

pre

senta

tions,

and T

RIC

AR

E

repre

senta

tive

s to

help

you m

ake

info

rmed d

eci

sions

about

TR

ICA

RE

pro

gram

s, m

edic

al p

rofe

ssio

nal

s,

and fac

ilities.

You

should

expect

a c

hoic

e o

f heal

th c

are

pro

viders

that

is

suffi

cient

to e

nsu

re

acce

ss t

o a

ppro

pri

ate h

igh-q

ual

ity

heal

th c

are.

You s

hould

expect

to

acc

ess

medic

ally

nece

ssar

y an

d

appro

pri

ate e

merg

ency

heal

th c

are

serv

ices

as is

reas

onab

ly a

vaila

ble

when

and w

here

the n

eed a

rise

s.

Y

ou s

hould

expect

to r

ece

ive a

nd r

evie

w in

form

atio

n

about

the d

iagn

osi

s, t

reat

ment,

and

pro

gress

of yo

ur

condit

ions,

and t

o fully

par

tici

pat

e in a

ll deci

sions

rela

ted t

o

your

heal

th c

are, or

to b

e r

epre

sente

d

by

fam

ily m

em

bers

or

oth

er

duly

ap

poin

ted r

epre

senta

tive

s.

You s

hould

expect

to r

ece

ive

consi

dera

te, re

spect

ful ca

re fro

m a

ll m

em

bers

of th

e h

eal

th c

are s

yste

m

wit

hout

dis

crim

inat

ion b

ased o

n r

ace,

colo

r, n

atio

nal

ori

gin, or

any

oth

er

bas

is r

eco

gniz

ed in a

pplic

able

law

or

regu

lations.

You s

hould

expect

to

com

munic

ate w

ith h

eal

th c

are

pro

viders

in c

onfidence

and t

o h

ave

the c

onfidenti

alit

y of yo

ur

heal

th c

are

info

rmat

ion p

rote

cted t

o t

he e

xte

nt

perm

itte

d b

y la

w. You a

lso s

hould

expect

to h

ave t

he a

bili

ty t

o r

evi

ew

, co

py,

and r

equest

am

endm

ents

to

your

medic

al r

eco

rds.

Y

ou s

hould

expect

a fai

r an

d e

ffici

ent

pro

cess

for

reso

lvin

g diffe

rence

s w

ith h

eal

th p

lans,

heal

th c

are p

rovi

ders

, an

d inst

itutions

that

serv

e y

ou.

Addit

ional

ly, D

oD

has

the follo

win

g expect

atio

ns

of

you a

s a

TR

ICA

RE

benefici

ary:

Y

ou s

hould

m

axim

ize h

eal

thy

hab

its

such

as

exerc

isin

g, n

ot

smokin

g, a

nd m

ainta

inin

g a

heal

thy

die

t.

You s

hould

be invo

lved in h

eal

th c

are

deci

sions,

whic

h m

ean

s w

ork

ing

wit

h

pro

vider

s to

pro

vide

rele

vant in

form

atio

n,

clear

ly c

om

munic

ate w

ants

and n

eeds,

an

d d

eve

lop a

nd c

arry

out

agre

ed-u

pon

treat

ment

pla

ns.

You s

hould

be k

now

ledge

able

about

TR

ICA

RE c

ove

rage

and p

rogr

am o

ptions.

S

how

resp

ect

for

oth

er

pat

ients

and

heal

th c

are w

ork

ers

.

Mak

e a

good-f

aith

effort

to m

eet

finan

cial

oblig

atio

ns.

Use

the d

ispute

d c

laim

s pro

cess

when

there

is

a dis

agre

em

ent.

“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.

Nove

mber

201

2

Important Information

Medic

are:

1-800-M

ED

ICA

RE (

1-800-6

33-4

227)

Soci

al S

ecu

rity

Adm

inis

trat

ion:

1-800-7

72-1

213

TR

ICA

RE W

eb S

ite:

ww

w.tri

care

.mil

TRICARE For Life Contractor

Wis

consi

n P

hys

icia

ns

Serv

ice:

1-866-7

73-0

404

TR

ICA

RE F

or

Life

Web S

ite:

ww

w.T

RIC

AR

E4u.c

om

TRICARE North Region Contractor

Heal

th N

et

Federa

l Se

rvic

es,

LLC

: 1-

877-

TR

ICA

RE (

1-877-

874

-2273)

Heal

th N

et

Web S

ite:

ww

w.h

nfs

.com

TRICARE South Region Contractor

Hum

ana

Mili

tary

, a

div

isio

n o

f

Hum

ana

Gove

rnm

ent

Busi

ness

: 1-

800-4

44-5

445

Hum

ana

Mili

tary

Web S

ite:

Hum

ana-

Mili

tary

.com

TRICARE West Region Contractor

Unit

edH

eal

thca

re M

ilita

ry &

Vete

rans:

1-

877-

988-W

EST

(1-

877-

988-9

378)

Unit

edH

eal

thca

re W

eb S

ite:

ww

w.u

hcm

ilita

ryw

est

.com

An I

mp

ort

ant

No

te A

bo

ut

TR

ICA

RE

Pro

gra

m C

ha

nges

At

the t

ime o

f pri

nting,

this

info

rmat

ion is

curr

ent.

It

is im

port

ant

to r

em

em

ber

that

T

RIC

AR

E p

olic

ies

and b

enefits

are

gove

rned b

y public

law

and federa

l regu

lations.

Chan

ges

to T

RIC

AR

E p

rogr

ams

are c

ontinual

ly m

ade a

s public

law

and

/or

federa

l re

gula

tions

are

amended. For

the m

ost

rece

nt

info

rmat

ion, co

nta

ct y

our

regi

onal

contr

acto

r or

loca

l T

RIC

AR

E S

erv

ice C

ente

r. M

ore

info

rmat

ion r

ega

rdin

g T

RIC

AR

E, in

cludin

g th

e H

eal

th

Insu

rance

Port

abili

ty a

nd A

ccounta

bili

ty A

ct (

HIP

AA

) N

otice

of Pri

vacy

Pra

ctic

es,

can

be

found o

nlin

e a

t w

ww

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Imp

ort

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t C

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form

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on

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th

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age

as

a g

uid

e fo

r th

e m

ost

im

port

an

t re

sourc

es a

vail

able

to y

ou

.

TR

ICA

RE’s

We

b S

ite: w

ww

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care

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TR

ICA

RE

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ffici

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bout

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ques

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in

form

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ou

r T

RIC

AR

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harm

acy b

enefi

t; t

o

dow

nlo

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and i

nst

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ions;

to l

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te a

TR

ICA

RE

Ser

vic

e C

ente

r or

mil

itary

trea

tmen

t fa

cili

ty; to

find a

TR

ICA

RE

Deb

t C

oll

ecti

on A

ssis

tance

Offi

cer;

and to a

nsw

er q

ues

tions

about su

rviv

or

cover

age,

loss

of

elig

ibil

ity,

and p

rog

ram

opti

on in

form

atio

n, am

ong o

ther

th

ings.

Subsc

rib

e to

TR

ICA

RE

For

Lif

e (T

FL

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gra

m u

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at

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Ge

ne

ral

Co

nta

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nfo

rmati

on

Gri

eva

nce

sC

laim

s

Phone:

18

66

773

04

04

Web

: w

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ICA

RE

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Wri

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Corr

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ICA

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n A

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ox 7

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ison, W

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ppea

ls a

nd g

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s w

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as

gen

era

l in

qu

irie

s.

Defe

nse E

nro

llm

en

t Eli

gib

ilit

y R

ep

ort

ing

Syste

m (

DE

ER

S)

DE

ER

S i

s a

dat

abas

e of

un

iform

ed s

ervic

e m

emb

ers

(spo

nso

rs),

fam

ily m

emb

ers,

and o

ther

s

worl

dw

ide

who a

re e

nti

tled

under

law

to m

ilit

ary

ben

efits

, in

clud

ing T

RIC

AR

E. S

ponso

rs a

re

requ

ired

to k

eep D

EE

RS

updat

ed, in

clud

ing t

hei

r re

siden

tial

and m

ail

ing a

dd

ress

for

them

selv

es

and e

lig

ible

dep

enden

ts.

You

have

sev

era

l o

pti

on

s fo

r u

pd

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ng

an

d v

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g D

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RS

in

form

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on

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on

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r Fa

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it a

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cal

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tifi

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TR

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Extr

a, 4

, 7

TR

ICA

RE

Manag

emen

t A

ctiv

ity,

9, 19

TR

ICA

RE

Over

seas

Pro

gra

m (

TO

P),

10,

13

–14

, 17

, 21

TR

ICA

RE

Pharm

acy H

om

e D

eliv

ery,

17–20

TR

ICA

RE

Plu

s, 1

1–12

TR

ICA

RE

Pri

me,

4, 7,

11–12

TR

ICA

RE

Reg

ional

Offi

ce, 23, 28

TR

ICA

RE

Ret

iree

Den

tal P

rogra

m (

TR

DP

),

13, 15

–16

TR

ICA

RE

Ser

vic

e C

ente

r (T

SC

), 2

2, 2

4

TR

ICA

RE

Sta

nd

ard

, 4, 7,

10

–11

TR

ICA

RE

supple

men

t, 9

TR

ICA

RE

You

ng A

du

lt, 26

TR

ICA

RE

all

ow

able

charg

e, 8

, 29

TR

ICA

RE

auth

ori

zed p

rovid

er, 12

, 30

U

Un

iform

ed s

ervic

es iden

tifi

cati

on (

ID)

card

,

7, 1

7–18

, 2

4–25

Un

ited

Hea

lthca

re M

ilit

ary

& V

eter

ans

(Un

ited

Hea

lthca

re),

14

U.S

. te

rrit

ori

es, 9

–10

, 16

, 18

, 20, 26

Urg

ent

care

, 13

–14

V

Vet

erans

Aff

air

s, 1

2, 2

4

W

Wis

consi

n P

hysi

cians

Ser

vic

e (W

PS

), 7

–9,

11, 14

–15, 22

, 28, 30

33

Hosp

ice

care

, 4, 14

Hosp

ital,

4, 12

, 16

Hu

mana

Mil

itary

, 14

I Iden

tifi

cati

on (

ID)

card

, 7,

17–18

, 2

4–25

Ind

ian H

ealt

h S

ervic

e, 9

L

Lim

itat

ions,

15, 19

Longt

erm

care

, 16

M

Marr

iage,

25

Med

icaid

, 4, 9

Med

ical

equ

ipm

ent,

5

Med

icare

Part

A, 1,

4–7

, 11

, 27

Med

icare

Part

B, 1,

4–7

, 10

–11

, 27

Med

icare

Part

D, 17

Med

icare

cer

tifi

ed p

rovid

er, 11

, 26

Med

icare

part

icip

atin

g p

rovid

er, 1,

4–17

,

22

–23, 27–28, 30

Med

icat

ion, 17

–20

Mem

ber

Choic

e C

ente

r, 1

8

Met

Lif

e, 1

5

Mil

itary

tre

atm

ent fa

cili

ty (

MT

F),

1, 11

–13,

15, 17

–18

, 20, 22

–23, 28

Movin

g, 26

N

Nat

ional

Guard

and R

eser

ve,

4, 15

–16

Net

work

pharm

acy,

17–21

Net

work

pro

vid

er, 29

Nonf

orm

ula

ry d

rugs,

17,

19

Nonn

etw

ork

pharm

acy,

17–18

, 20

Nonn

etw

ork

pro

vid

er, 29

Nonpart

icip

atin

g p

rovid

er, 1,

12

O

Occ

upat

ional

ther

apy,

16

Oth

er h

ealt

h i

nsu

rance

(O

HI)

, 1,

8–11

, 16

,

18, 22

Out

of

po

cket

cost

s, 7

–9,

11–12

, 15, 18

Outp

atie

nt

care

, 5

P

Part

icip

atin

g p

rovid

er, 29

Pay

men

t, 5

–8, 11

–12

, 14

, 21

–22

, 27–28

Pharm

acy,

1, 17

–21

Physi

cal

ther

apy,

16

Pre

miu

m, 4

–7,

10

–11

, 27

Pre

scri

pti

on, 17

–21

Pre

ven

tive

care

, 5

Pri

me

Ser

vic

e A

rea

(PS

A),

4, 7

Pri

or

auth

ori

zati

on, 11

, 14

, 16

, 19

, 28

Pro

gra

m o

pti

ons,

7, 26

Q

Quanti

ty l

imit

s, 1

9

R

Ref

erra

l, 1

1

Rei

mbu

rsem

ent,

17–18

, 21

, 23

Ren

al

dis

ease

, 4

Ret

ail

net

work

pharm

acy,

18

–21

Ret

ired

, 4

–6, 11

–13, 15

–16

, 2

4–25

S

Sh

ips,

9–10

Sk

ille

d n

urs

ing c

are

, 16

Sk

ille

d n

urs

ing f

acil

ity (

SN

F),

4, 16

So

cial

Sec

uri

ty A

dm

inis

trat

ion (

SS

A),

4–7

So

cial

Sec

uri

ty n

um

ber

(S

SN

), 5

, 7,

22

,

25, 27,

29

–30

Spac

eav

ail

able

care

, 11

–12

Spec

ialt

y M

edic

atio

n C

are

Man

agem

ent,

20

Spec

ialt

y m

edic

atio

n, 20

Sp

eech

ther

apy,

16

Spouse

, 4

–7,

11,

22

, 25

–27

Su

rviv

or,

4, 16

, 26

T

Th

irdp

art

y l

iabil

ity,

23

Tra

nsp

lants

, 14

Tra

vel

, 10

, 13, 17

SECTION 9

INDEX

TR

ICA

RE R

eg

ion

al

Co

ntr

acto

rs

Reg

ional co

ntr

acto

rs p

rovid

e hea

lth c

are

ser

vic

es a

nd s

upport

in the

TR

ICA

RE

reg

ions

and c

an

hel

p T

FL

ben

efici

arie

s w

ith p

rior

auth

ori

zati

ons,

but do n

ot pro

vid

e re

ferr

als

for

TF

L b

enefi

ciar

ies.

Wis

consi

n P

hysi

cians

Ser

vic

e ad

min

iste

rs t

he

TF

L p

rog

ram

and s

hou

ld b

e you

r pri

mary

conta

ct f

or

TR

ICA

RE

rel

ated

cust

om

er s

ervic

e nee

ds

in t

he

Un

ited

Sta

tes

or

U.S

. te

rrit

ori

es

(Am

eric

an S

am

oa

, G

ua

m, th

e N

ort

her

n M

ari

an

a I

sla

nd

s, P

uer

to R

ico, a

nd t

he

U.S

. Vir

gin

Isla

nd

s). G

o t

o w

ww

.med

ica

re.g

ov

and c

lick

on “

Fac

ilit

ies

& D

oct

ors

” fo

r hel

p fi

nd

ing

pro

vid

ers.

Over

seas

, co

nta

ct y

ou

r T

RIC

AR

E O

ver

seas

Pro

gra

m (

TO

P)

Reg

ional

Call

Cen

ter.

Reg

ion

al

Con

tra

cto

rs (

Sta

tesi

de)

TR

ICA

RE

No

rth

Re

gio

nT

RIC

AR

E S

ou

th R

eg

ion

TR

ICA

RE

We

st R

eg

ion

Hea

lth

Net

Fed

era

l S

erv

ices

, L

LC

1

877

TR

ICA

RE

(1

877

874

2273)

w

ww

.hn

fs.c

om

Hu

ma

na M

ilit

ary

, a d

ivis

ion

of

Hu

ma

na G

over

nm

ent

Bu

sin

ess

180

04

44

54

45

H

um

ana

Mil

itary

.com

Un

ited

Hea

lth

care

M

ilit

ary

& V

eter

an

s 1

877

988

WE

ST

(1

877

988

9378)

w

ww

.uhcm

ilit

ary

wes

t.co

m

Reg

ion

al

Con

tra

cto

r (O

ver

sea

s)

TR

ICA

RE

Eu

rasi

a-A

fric

aT

RIC

AR

E L

ati

n A

me

rica

a

nd

Ca

na

da

TR

ICA

RE

Pa

cifi

c

TR

ICA

RE

Over

sea

s P

rog

ram

(T

OP

) R

egio

na

l C

all

Cen

ter

+

44

20

8762

838

4 (

ove

rsea

s)

18776

78

12

07 (

sta

tesi

de)

tr

icare

lon@

inte

rnat

ionals

os.

com

TO

P R

egio

na

l C

all

Cen

ter

+1

215

942

8393 (

ove

rsea

s)

18774

518

659 (

sta

tesi

de)

tr

icare

ph

l@in

tern

atio

nals

os.

com

TO

P R

egio

na

l C

all

Cen

ters

Sin

gapore

: +

656

3392

676

(ove

rsea

s)

18776

78

12

08 (

sta

tesi

de)

si

n.t

rica

re@

inte

rnat

ionals

os.

com

Syd

ney:

+61

29

273

271

0 (

ove

rsea

s)

18776

78

12

09 (

sta

tesi

de)

sy

dtr

icare

@in

tern

atio

nals

os.

com

Oth

er C

on

tact

In

form

ati

on

Fo

r M

ore

In

form

ati

on

Re

sou

rce

Nu

mb

ers

We

b S

ite

s

Med

icare

18

00

633

4227

ww

w.m

edic

are

.gov

So

cial

Sec

uri

ty A

dm

inis

trat

ion

18

00

772

1213

ww

w.s

sa.g

ov

TR

ICA

RE

Pharm

acy P

rog

ram

18

773

63

13

03

ww

w.t

ric

are

.mil

/ph

arm

acy

w

ww

.ex

pre

sss

crip

ts.c

om

/TR

ICA

RE

Pre

scri

pti

on D

rug F

orm

ula

ry S

earc

h18

773

63

13

03

ww

w.p

ec.h

a.o

sd.m

il/

form

ula

ry_

sea

rch

.ph

p

TR

ICA

RE

Den

tal

Pro

gra

m18

55

63

88

371

(st

ate

sid

e)

18

55

63

88

372

(ove

rsea

s)

18

55

63

88

373

(T

DD

/TT

Y)

htt

ps:

//m

yb

enefi

ts.m

etli

fe.c

om

/tric

are

TR

ICA

RE

Ret

iree

Den

tal P

rogra

m18

88

83

88

737

ww

w.t

rdp

.org

Offi

ce o

f P

erso

nnel

Manag

emen

t18

88

7676

73

8

18

00

582

3337

ww

w.o

pm

.gov/f

orm

s w

ww

.op

m.g

ov/i

nsu

re/l

tc

Fin

d a

Deb

t C

oll

ecti

on A

ssis

tance

O

ffice

r or

a B

enefi

ciary

Counse

ling

and A

ssis

tance

Co

ord

inat

or

See

Web

sit

ew

ww

.tric

are

.mil

/bcacd

cao

Fin

d a

mil

itary

tre

atm

ent

faci

lity

See

Web

sit

ew

ww

.tric

are

.mil

/mtf

Toll

fre

e over

seas

conta

ct

info

rmat

ion

See

ch

art

ab

ove

ww

w.t

ric

are

over

sea

s.co

m

1

Wel

com

e to

TR

ICA

RE

Fo

r L

ife

TR

ICA

RE

For

Lif

e (T

FL

) is

the

Med

icare

wra

paro

und c

over

age

for

TR

ICA

RE

ben

efici

ari

es w

ho h

ave

Med

icare

Part

A a

nd M

edic

are

Part

B,

regard

less

of

age

or

pla

ce o

f re

siden

ce.

TF

L p

rovid

es c

om

pre

hen

sive

hea

lth c

are

cover

age.

You h

ave

the

free

dom

to s

eek

care

fro

m a

ny M

edic

are

part

icip

atin

g o

r

nonpart

icip

atin

g p

rov

ider

, or

mil

itary

trea

tmen

t fa

cili

ty o

n a

spac

eav

ail

able

bas

is. M

edic

are

part

icip

atin

g p

rovid

ers

file

you

r cl

aim

s w

ith M

edic

are

. A

fter

pay

ing i

ts p

ort

ion, M

edic

are

auto

mat

icall

y

forw

ard

s th

e cl

aim

to T

RIC

AR

E f

or

pro

cess

ing (

unle

ss y

ou h

ave

oth

er h

ealt

h

insu

ran

ce [

OH

I]).

TR

ICA

RE

pay

s aft

er

Med

icare

and O

HI

for

cover

ed h

ealt

h

care

ser

vic

es.

Th

is h

andb

ook

wil

l hel

p y

ou

make

the

most

of

you

r T

FL

cover

age.

You w

ill

find

info

rmat

ion a

bout

elig

ibil

ity r

equ

irem

ents

,

get

ting

care

, and

cla

ims.

Th

is h

andb

ook

als

o p

rovid

es d

etail

s ab

out

you

r pharm

acy

and d

enta

l co

ver

age

opti

ons.

32

Ind

ex

A

Acc

iden

t, 2

3

Act

ive

duty

fam

ily m

emb

er (

AD

FM

),

4–5, 12

Act

ive

duty

ser

vic

e m

emb

er (

AD

SM

),

4–5, 12

, 15, 17

, 2

4

Act

ive

duty

sponso

r, 1

1, 1

6

Acu

pu

nct

ure

, 15

Age

lim

itat

ions,

19,

26

All

ow

able

charg

e, 8

, 12

, 29

App

eal,

8, 21

–23, 28

–29

Appoin

tmen

t, 1

1–12

, 14

, 29

Auth

ori

zati

on, 11

, 14

, 16

, 19

, 22

, 28

–29

B

Beh

avio

ral

hea

lth c

are

, 14

Ben

efici

ary

Cou

nse

ling a

nd A

ssis

tance

Coord

inat

or

(BC

AC

), 2

3, 28

Bil

l, 5

–6, 8, 12

, 22

–23, 27

Bra

ndn

am

e d

rug, 19

C

Cen

ters

for

Med

icare

& M

edic

aid

Ser

vic

es, 4

Cer

tifi

cate

of

cred

itab

le c

over

age,

26

–27

Charg

e, 8

–9,

12

, 22

, 29

Ch

ild

ren, 26

–27,

30

Cla

im, 1,

7–10

, 12

–14

, 17

–18

, 20

–23, 28

Com

mon A

cces

s C

ard

(C

AC

), 1

7, 2

4–25

Conti

nued

Hea

lth C

are

Ben

efit

Pro

gra

m

(CH

CB

P),

26

Copay

men

t, 8

, 17

–19

Cost

share

, 8

–10

, 12

, 18

Cust

od

ial

care

, 16

D

Deb

t C

oll

ecti

on A

ssis

tance

Offi

cer

(DC

AO

), 2

3

Ded

uct

ible

, 8

–10

, 12

, 18

Def

ense

En

roll

men

t E

lig

ibil

ity R

eport

ing

Syst

em (

DE

ER

S),

7, 2

4–27

Def

ense

Manpow

er D

ata

Cen

ter

Support

Offi

ce, 27

Del

ta D

enta

l® o

f C

ali

forn

ia

(Del

ta D

enta

l), 16

Den

tal

care

, 13

–14

Dep

enden

t ch

ild

, 27,

30

Dis

abil

ity,

4–5, 14

, 26

–27

Div

orc

e, 5

, 7,

25

–27

Du

rable

med

ical

equ

ipm

ent,

5

E

Eli

gib

ilit

y, 1

, 4

–7, 11

, 13, 15

–16

, 22

,

24

–27,

29

–30

Em

ergen

cy, 13

–14

Ends

tage

renal

dis

ease

(E

SR

D),

4–5

En

roll

men

t, 4

–7, 11

–13, 17

, 2

4, 26

–27

Expla

nat

ion o

f b

enefi

ts (

EO

B),

22

–23,

28

–29

Expre

ss S

crip

ts, In

c. (

Expre

ss S

crip

ts),

17–21

Eye

exam

inat

ions,

15

F

Fed

eral

Em

plo

yee

s H

ealt

h B

enefi

ts

(FE

HB

), 1

1

Form

er s

pouse

, 4, 11

, 22

, 25, 27

G

Gen

eric

dru

g, 17

, 19

Gen

eric

equ

ivale

nt,

19

Gri

evance

, 30

Guard

ian, 30

H

Hea

lth N

et F

eder

al

Ser

vic

es, L

LC

(Hea

lth N

et),

14

Hea

ring a

ids,

15

Hom

e hea

lth c

are

, 4

–5

31

Lis

t o

f Fi

gu

res

Fig

ure

1.1

T

RIC

AR

E F

or

Lif

e O

ut

of

Po

cket

Cost

s ......................................................

9

Fig

ure

2.1

M

TF

Appoin

tmen

t P

riori

ties

.......................................................................1

2

Fig

ure

4.1

T

RIC

AR

E P

harm

acy H

om

e D

eliv

ery R

egis

trat

ion M

etho

ds

.....................1

8

Fig

ure

6.1

E

lig

ibil

ity R

equ

irem

ents

for

Form

er S

pouse

s .............................................2

5

Fig

ure

7.1

T

RIC

AR

E F

or

Lif

e A

pp

eals

Req

uir

emen

ts ..

..............................................

29

SECTION 7

FOR INFORMATION AND ASSISTANCE

SECTION 8

LIST OF FIGURES

2

Tab

le o

f C

on

ten

ts

1.

Ho

w T

RIC

AR

E F

or

Lif

e W

ork

s ...

....

....

....

....

....

......

....

....

....

....

....

....

....

...4

Eli

gib

ilit

y ..

....................................................................................................................

4

Under

stand

ing M

edic

are

..............................................................................................4

Fre

quen

tly A

sked

Ques

tions:

Med

icare

........................................................................6

How

TR

ICA

RE

For

Lif

e W

ork

s w

ith M

edic

are

...........................................................7

Fre

quen

tly A

sked

Ques

tions:

How

TR

ICA

RE

For

Lif

e W

ork

s ..................................

10

2.

Gett

ing

Care

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

.12

Fin

din

g a

Pro

vid

er ..

....................................................................................................

12

Em

ergen

cy C

are

.........................................................................................................1

3

Urg

ent

Care

................................................................................................................1

3

Beh

avio

ral

Hea

lth C

are

..............................................................................................1

4

Pri

or

Auth

ori

zati

on f

or

Care

.......................................................................................1

4

3.

TR

ICA

RE F

or

Lif

e C

overa

ge ..

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

15

TR

ICA

RE

Med

ical

Cover

age .....................................................................................1

5

Den

tal

Cover

age

.........................................................................................................1

5

Fre

quen

tly A

sked

Ques

tions:

TR

ICA

RE

For

Lif

e C

over

age

......................................

16

4.

Ph

arm

acy ..

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

17

Pre

scri

pti

on D

rug C

over

age

.......................................................................................1

7

Fil

ling P

resc

ripti

ons

...................................................................................................1

7

Pharm

acy P

oli

cy ..

.......................................................................................................1

9

Pharm

acy C

laim

s .......................................................................................................2

0

5.

Cla

ims ..

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

....

.22

Hea

lth C

are

Cla

ims

....................................................................................................

22

App

eali

ng a

Cla

im o

r A

uth

ori

zati

on D

enia

l ...............................................................

22

Th

irdP

art

y L

iabil

ity ..

................................................................................................

23

Expla

nat

ion o

f B

enefi

ts ..

.............................................................................................2

3

Deb

t C

oll

ecti

on A

ssis

tance

Offi

cers

...........................................................................2

3

3

6.

Lif

e C

han

ges: U

pd

ate

Yo

ur

DE

ER

S R

eco

rd ..

................................

...2

4

Usi

ng m

ilC

on

nec

t to

Up

dat

e In

form

atio

n i

n D

EE

RS

.................................................2

4

Get

ting M

arr

ied o

r D

ivorc

ed .

....................................................................................

25

Ch

ild

ren

......................................................................................................................

26

Movin

g .......................................................................................................................

26

Su

rviv

or

Cover

age

......................................................................................................

26

Loss

of

Eli

gib

ilit

y ..

.....................................................................................................2

6

Susp

ensi

on o

f S

oci

al

Sec

uri

ty D

isab

ilit

y I

nsu

rance

...................................................2

7

7.

Fo

r In

form

ati

on

an

d A

ssi

sta

nce .................

..................................

..28

Ben

efici

ary

Cou

nse

ling a

nd A

ssis

tance

Coord

inat

ors

................................................

28

You

r R

ight

to A

pp

eal

a D

ecis

ion

................................................................................

28

Fil

ing a

Gri

evance

......................................................................................................

30

8.

Lis

t o

f Fig

ure

s .............

..................................

................................

...31

9.

Ind

ex ..

....

....

..................

..................................

................................

...32

See

the

insi

de

bac

k c

over

of

this

handbook f

or

“T

RIC

AR

E E

xp

ecta

tions

for

Ben

efici

ari

es.”

30

Filin

g a

Grie

vance

A g

riev

ance

is

a w

ritt

en c

om

pla

int

or

conce

rn a

bout

a nona

pp

eala

ble

iss

ue

regard

ing a

per

ceiv

ed f

ail

ure

by a

ny

mem

ber

of

the

TF

L h

ealt

h c

are

del

iver

y

team

, in

clud

ing T

RIC

AR

Ea

uth

ori

zed

pro

vid

ers

or

mil

itary

pro

vid

ers,

to p

rovid

e

appro

pri

ate

and t

imel

y h

ealt

h c

are

ser

vic

es,

acce

ss, or

quali

ty, or

to d

eliv

er t

he

pro

per

level

of

care

or

serv

ice.

The

TF

L g

riev

ance

pro

cess

pro

vid

es t

he

opport

un

ity t

o r

eport

, in

wri

ting, any

conce

rn o

r co

mpla

int

regard

ing h

ealt

h

care

quali

ty o

r se

rvic

e. A

ny T

FL

civ

ilia

n

or

mil

itary

pro

vid

er;

TF

L b

enefi

ciary

;

sponso

r; o

r pare

nt,

guard

ian, or

oth

er

repre

senta

tive

of

an e

lig

ible

dep

enden

t

chil

d m

ay fi

le a

gri

evance

. W

PS

is

resp

onsi

ble

for

the

inves

tigat

ion a

nd

reso

luti

on o

f all

gri

evance

s.

Gri

evance

s are

gen

erall

y r

esolv

ed w

ith

in

60 d

ays

of

rece

ipt.

Foll

ow

ing r

esolu

tion,

the

part

y t

hat

subm

itte

d t

he

gri

evance

is

noti

fied

of

the

revie

w c

om

ple

tion.

Gri

evance

s m

ay i

ncl

ude

such

iss

ues

as:

• T

he

quali

ty o

f hea

lth c

are

or

serv

ices

(e.g

., a

cces

sibil

ity,

appro

pri

ate

nes

s,

leve

l, c

on

tin

uit

y, t

imel

ines

s of

care

)

• T

he

dem

eanor

or

beh

avio

r of

pro

vid

ers

and t

hei

r st

aff

mem

ber

s

• T

he

per

form

ance

of

any p

art

of

the

hea

lth

care

del

iver

y s

yst

em

• P

ract

ices

rel

ated

to p

atie

nt

safe

ty

When

fili

ng a

gri

evance

, in

clude

the

foll

ow

ing i

nfo

rmat

ion:

• B

enefi

ciary

’s n

am

e, a

dd

ress

, and

tele

phone

nu

mb

er

• S

ponso

r’s

SS

N o

r D

BN

• B

enefi

ciary

’s d

ate

of

bir

th

• B

enefi

ciary

’s s

ignat

ure

A d

escr

ipti

on o

f th

e is

sue

or

conce

rn m

ust

incl

ude

the

foll

ow

ing:

• D

ate

and t

ime

of

the

even

t

• N

am

e(s)

of

the

pro

vid

er(s

) and

/or

per

son(s

) in

volv

ed

• A

dd

ress

of

the

even

t

• N

atu

re o

f th

e co

nce

rn o

r co

mpla

int

• D

etail

s des

crib

ing t

he

even

t or

issu

e

• A

ny a

ppro

pri

ate

support

ing d

ocu

men

ts

Conta

ct M

edic

are

to fi

le M

edic

are

rel

ated

gri

evance

s.

29

App

eals

shou

ld c

onta

in t

he

foll

ow

ing:

• B

enefi

ciary

’s n

am

e, a

dd

ress

, and

tele

phone

nu

mb

er

• S

ponso

r’s

So

cial

Sec

uri

ty n

um

ber

(S

SN

)

or

Dep

art

men

t of

Def

ense

Ben

efits

Nu

mb

er (

DB

N)

• B

enefi

ciary

’s d

ate

of

bir

th

• B

enefi

ciar

y’s

or

appea

ling p

arty

’s s

ignat

ure

A d

escr

ipti

on o

f th

e is

sue

or

conce

rn

must

incl

ude:

• T

he

spec

ific

issu

e in

dis

pute

• A

copy o

f th

e pre

vio

us

den

ial

det

erm

inat

ion n

oti

ce

• A

ny a

ppro

pri

ate

support

ing

do

cum

ents

TR

ICA

RE

Fo

r L

ife

Ap

pea

ls R

equ

irem

ents

Fig

ure

7.1

1A

n a

ppro

pri

ate

app

eali

ng

part

y m

ust

subm

it t

he

app

eal.

Pro

per

app

eali

ng

part

ies

incl

ude:

• Y

ou,

the

ben

efici

ary

• N

onn

etw

ork

part

icip

atin

g p

rov

ider

s

If a

part

y o

ther

than

those

lis

ted

above

subm

its

the

app

eal,

you

wil

l gen

erall

y b

e re

qu

ired

to c

om

ple

te a

nd

sig

n a

n A

pp

oin

tmen

t o

f R

epre

sen

tati

ve f

orm

, w

hic

h i

s av

ail

able

on

you

r

reg

ional

contr

acto

r’s

Web

sit

e. A

pp

eals

subm

itte

d w

ithout

this

form

wil

l not

be

pro

cess

ed,

exce

pt

in t

he

foll

ow

ing

cas

es:

• A

cust

od

ial

pare

nt

subm

its

an

app

eal

on

beh

alf

of

a m

inor

ben

efici

ary

• A

n a

ttorn

ey fi

les

an

app

eal

wit

hout

spec

ific

app

oin

tmen

t by

the

pro

per

app

eali

ng

part

y

Note

: N

etw

ork

pro

vid

ers

are

not

appro

pri

ate

app

eali

ng

part

ies,

but

may

be

app

oin

ted

as

repre

senta

tives

, in

wri

ting,

by

you.

2T

he

app

eal

must

be

subm

itte

d i

n w

riti

ng.

3T

he

issu

e in

dis

pute

must

be

an

app

eala

ble

iss

ue.

The

foll

ow

ing

are

not

app

eala

ble

iss

ues

:

• A

llow

able

charg

es

• E

lig

ibil

ity

• D

enia

l of

serv

ices

fro

m a

n u

nau

thori

zed

pro

vid

er

• D

enia

l of

trea

tmen

t pla

n w

hen

an

alt

ernat

ive

trea

tmen

t pla

n i

s se

lect

ed

4A

n a

pp

eal

must

be

file

d w

ith

in 9

0 d

ays

of

the

dat

e on

the

expla

nat

ion

of

ben

efits

or

den

ial

noti

fica

tion

let

ter.

5T

her

e m

ust

be

an a

mount

in d

ispute

to fi

le a

n a

ppea

l. I

n c

ases

invo

lvin

g a

n a

ppea

l of

a

den

ial

of

an

auth

ori

zati

on

in

advance

of

rece

ivin

g t

he

actu

al

serv

ices

, th

e am

ou

nt

in

dis

pute

is

dee

med

to

be

the

esti

mat

ed T

RIC

AR

Ea

llow

able

charg

e fo

r th

e se

rvic

es

reques

ted.

Ther

e is

no

min

imu

m a

mou

nt

to r

eques

t a

reco

nsi

der

atio

n.

SECTION 7

FOR INFORMATION AND ASSISTANCE

4

Ho

w T

RIC

AR

E F

or

Lif

e W

ork

s

Eligib

ilit

y

TR

ICA

RE

For

Lif

e (T

FL

) is

avail

able

to

TR

ICA

RE

ben

efici

ari

es, re

gard

less

of

age

and p

lace

of

resi

den

ce, i

f yo

u h

ave

Med

icare

Par

t A

and M

edic

are

Par

t B

. You a

re e

ligib

le

for

TF

L o

n t

he

firs

t d

ate

that

you h

ave

both

Med

icare

Part

A a

nd M

edic

are

Part

B.

TR

ICA

RE E

lig

ibil

ity R

eq

uir

em

en

ts

When

you a

re e

nti

tled

to p

rem

ium

fre

e

Med

icare

Part

A:

• M

edic

are

Part

B c

over

age

is r

equ

ired

to

rem

ain

TR

ICA

RE

eli

gib

le i

f you a

re a

:

• R

etir

ed s

ervic

e m

emb

er (

incl

udin

g

reti

red N

ati

on

al

Gu

ard

an

d R

eser

ve

mem

ber

s dra

win

g r

etir

emen

t p

ay)

• F

am

ily m

emb

er o

f a

reti

red

serv

ice

mem

ber

• M

edal

of

Honor

reci

pie

nt

or

elig

ible

fam

ily m

emb

er

• S

urv

ivor

of

a dec

ease

d s

ponso

r

• Q

uali

fyin

g f

orm

er s

pouse

• M

edic

are

Part

B c

over

age

is n

ot

requ

ired

to r

emain

TR

ICA

RE

eli

gib

le i

f:

• Y

ou a

re a

n a

ctiv

e duty

ser

vic

e m

emb

er

(AD

SM

) or

acti

ve

duty

fam

ily m

emb

er

(AD

FM

) (A

DS

Ms

an

d A

DF

Ms

rem

ain

elig

ible

for

TR

ICA

RE

Pri

me a

nd

TR

ICA

RE

Sta

nd

ard

an

d T

RIC

AR

E

Extr

a o

pti

on

s w

hil

e th

e sp

on

sor

is o

n

act

ive

duty

. H

ow

ever

, w

hen

the

sponso

r

reti

res,

you m

ust

have

Med

icare

Part

B

to r

ema

in T

RIC

AR

Ee

ligib

le. See

“M

edic

are

Part

B [

Med

ical

Insu

rance

]”

on t

he

foll

ow

ing p

age

for

info

rma

tio

n

abou

t th

e M

edic

are

Part

B s

pec

ial

enro

llm

ent

per

iod f

or

AD

SM

s a

nd

AD

FM

s.)

Note

: R

egard

less

of

age,

AD

FM

s w

ho h

ave

Med

icare

Part

A m

ay e

nro

ll i

n T

RIC

AR

E

Pri

me

if t

hey

liv

e in

a T

RIC

AR

E P

rim

e

Ser

vic

e A

rea

(PS

A).

The

TR

ICA

RE

Pri

me

enro

llm

ent

fee

is w

aiv

ed f

or

reti

ree

fam

ily

mem

ber

s w

ith M

edic

are

Part

B c

over

age.

Understa

ndin

g M

edic

are

TF

L i

s m

anag

ed

by

the

Dep

art

men

t

of

Def

ense

. M

ed

icare

is

manag

ed

by

the

Cen

ters

for

Med

icare

& M

edic

aid

Ser

vic

es (

CM

S).

The

two a

gen

cies

work

toget

her

to c

oord

inat

e b

enefi

ts.

Med

icare

is

a fe

der

al

enti

tlem

ent

hea

lth

insu

rance

pro

gra

m f

or

peo

ple

:

• A

ge

65 o

r old

er

• U

nder

age

65 w

ith c

erta

in d

isab

ilit

ies

• A

ny a

ge

wit

h e

nds

tage

renal

dis

ease

(E

SR

D)

Med

icare

Part

A (

Ho

sp

ital In

su

ran

ce)

Med

icare

Part

A c

over

s in

pat

ient

hosp

ital

care

, hosp

ice

care

, in

pat

ient sk

ille

d n

urs

ing

faci

lity

care

, and s

om

e hom

e hea

lth c

are

.

The

So

cial

Sec

uri

ty A

dm

inis

trat

ion (

SS

A)

det

erm

ines

you

r en

titl

emen

t to

Med

icare

Part

A b

ased

on y

ou

r w

ork

his

tory

or

you

r

spouse

’s w

ork

his

tory

. Y

ou a

re e

lig

ible

for

pre

miu

mf

ree

Med

icare

Part

A a

t ag

e 65

if y

ou o

r you

r sp

ouse

has

40 q

uart

ers

or

10 y

ears

of

So

cial

Sec

uri

tyc

over

ed

emplo

ym

ent.

5

If, w

hen

you t

urn

65, yo

u a

re n

ot el

igib

le f

or

pre

miu

mf

ree

Med

icare

Part

A u

nder

you

r

ow

n S

oci

al

Sec

uri

ty n

um

ber

(S

SN

), y

ou

must

file

for

ben

efits

under

you

r sp

ouse

’s

(this

incl

udes

div

orc

ed o

r dec

ease

d s

pouse

s)

SS

N, i

f he

or

she

is 6

2 o

r old

er. I

f yo

ur

spouse

is n

ot yet

62

, you s

hou

ld e

nro

ll in M

edic

are

Part

B a

t ag

e 65 to a

void

pay

ing a

su

rcharg

e

for

late

en

roll

men

t, a

nd y

ou s

hou

ld fi

le f

or

Part

A b

enefi

ts u

nder

you

r sp

ouse

’s r

ecord

when

he

or

she

turn

s 62.

Med

icare

Part

B (

Med

ical

Insu

ran

ce)

Med

icare

Part

B c

over

s pro

vid

er s

ervic

es,

outp

atie

nt

care

, pre

ven

tive

care

, hom

e

hea

lth c

are

, and d

ura

ble

med

ical

equip

men

t.

Med

icare

Part

B h

as a

month

ly p

rem

ium

,

wh

ich m

ay c

hange

an

nuall

y a

nd v

ari

es

bas

ed o

n i

nco

me.

If

you s

ign u

p a

fter

you

r

init

ial

enro

llm

ent

per

iod f

or

Med

icare

Part

B, you m

ay h

ave

to p

ay a

month

ly

pre

miu

m s

urc

harg

e fo

r as

long a

s you

hav

e M

edic

are

Part

B. T

he

surc

harg

e is

10 p

erce

nt

for

each

12m

onth

per

iod t

hat

you w

ere

elig

ible

for

Med

icare

Part

B b

ut

did

not

enro

ll.

Med

icare

all

ows

AD

SM

s an

d A

DF

Ms

who

are

enti

tled

to M

edic

are

bas

ed o

n a

ge

or

dis

abil

ity (d

oes

not a

pply

to th

ose

with E

SR

D)

to d

elay

Part

B e

nro

llm

ent

and s

ign u

p

du

ring a

sp

ecia

l en

roll

men

t p

erio

d, w

hic

h

waiv

es t

he

late

en

roll

men

t su

rcharg

e. T

he

spec

ial

enro

llm

ent

per

iod f

or

AD

SM

s and

AD

FM

s is

avail

able

any t

ime

the

sponso

r

is o

n a

ctiv

e duty

or

wit

hin

eig

ht

month

s

foll

ow

ing e

ither

(1)

the

sponso

r’s

reti

rem

ent

or

(2)

the

end o

f T

RIC

AR

E c

over

age,

wh

ichev

er c

om

es fi

rst.

To a

void

a b

reak i

n

cove

rage,

AD

SM

s an

d A

DF

Ms

must

sig

n u

p

for

Med

icare

Part

B b

efore

sponso

rs r

etir

e.

Note

: If

you h

ave

ES

RD

, si

gn u

p f

or

Med

icare

Part

A a

nd P

art

B a

s so

on

as y

ou a

re e

lig

ible

to a

void

a b

reak i

n

TR

ICA

RE

cover

age

and t

he

Med

icare

Part

B lat

een

roll

men

t pre

miu

m s

urc

harg

e.

Med

icare

En

titl

em

en

t B

ased

on

a D

isa

bil

ity

If y

ou r

ecei

ve

dis

abil

ity b

enefi

ts f

rom

the

SS

A, you a

re e

nti

tled

to M

edic

are

in t

he

25th

month

of

rece

ivin

g d

isab

ilit

y p

aym

ents

.

The

CM

S w

ill noti

fy y

ou o

f you

r M

edic

are

enti

tlem

ent

dat

e.

If y

ou r

etu

rn t

o w

ork

and y

ou

r S

oci

al

Sec

uri

ty d

isab

ilit

y p

aym

ents

are

susp

ended

,

you

r M

edic

are

enti

tlem

ent

conti

nues

for

up t

o e

ight

yea

rs a

nd s

ix m

onth

s. W

hen

you

r d

isab

ilit

y p

aym

ents

are

susp

ended

,

you w

ill

rece

ive

a bil

l ev

ery t

hre

e m

onth

s

for

you

r M

ed

icare

Part

B p

rem

ium

s.

You m

ust

conti

nue

to p

ay y

ou

r M

edic

are

Part

B p

rem

ium

s to

rem

ain

eli

gib

le f

or

TR

ICA

RE

cover

age.

SECTION 1

HOW TRICARE FOR LIFE WORKS

28

Fo

r In

form

ati

on

an

d A

ssis

tan

ce

Benefi

cia

ry C

ounseling a

nd

Assis

tance C

oordin

ato

rs

TR

ICA

RE

Ben

efici

ary

Cou

nse

ling a

nd

Ass

ista

nce

Coord

inat

ors

(B

CA

Cs)

can

hel

p y

ou w

ith T

RIC

AR

E F

or

Lif

e (T

FL

)

ques

tions

and c

once

rns,

and they

can

advis

e

you a

bout

obta

inin

g h

ealt

h c

are

. B

CA

Cs

are

lo

cate

d a

t m

ilit

ary

tre

atm

ent

faci

liti

es

and T

RIC

AR

E R

egio

nal

Offi

ces.

To lo

cate

a B

CA

C, vis

it t

he

on

line

dir

ecto

ry a

t

ww

w.t

ric

are

.mil

/bca

cdca

o.

Your

Rig

ht

to A

ppeal a D

ecis

ion

If y

ou b

elie

ve

a se

rvic

e or

claim

was

den

ied i

mpro

per

ly, in

whole

or

in p

art

,

you (

or

an

oth

er a

ppro

pri

ate

part

y) m

ay

file

an a

pp

eal.

An a

pp

eal

must

involv

e

an a

pp

eala

ble

iss

ue.

For

exam

ple

, you

hav

e th

e ri

ght

to a

ppea

l M

edic

are

or

TF

L

dec

isio

ns

regard

ing c

laim

s pay

men

ts.

Med

icare

and T

FL

hav

e se

para

te c

laim

s

pro

cess

es. F

or

most

ser

vic

es, M

edic

are

is

you

r pri

mary

pay

er. If

you w

ant

to a

pp

eal

a M

edic

are

dec

isio

n, you m

ust

conta

ct

Med

icare

. C

onta

ct W

isco

nsi

n P

hysi

cians

Ser

vic

e (W

PS

) to

app

eal

TF

L d

ecis

ions.

Med

icare

Den

ials

Any s

ervic

es o

r su

ppli

es d

enie

d p

aym

ent by

Med

icare

and a

pp

eala

ble

under

Med

icare

are

not

consi

der

ed f

or

cover

age

by T

FL

.

How

ever

, if

a M

edic

are

app

eal

resu

lts

in

som

e pay

men

t by M

edic

are

, T

RIC

AR

E

consi

der

s co

ver

age

as t

he

seco

nd p

ayer

.

For

more

in

form

atio

n o

n M

edic

are

appea

ls,

read

the

bac

k o

f you

r M

edic

are

Su

mm

ary

noti

ce o

r co

nta

ct M

edic

are

.

TR

ICA

RE F

or

Lif

e A

pp

eals

R

eq

uir

em

en

ts

You m

ay a

ppea

l a

TF

L d

enia

l of

a re

ques

ted

auth

ori

zati

on o

f se

rvic

es e

ven

if

no c

are

was

pro

vid

ed a

nd n

o c

laim

was

subm

itte

d. T

her

e

are

som

e th

ings

you m

ay n

ot

app

eal.

For

exam

ple

, w

hen

TF

L i

s th

e pri

mary

pay

er,

you m

ay n

ot

app

eal

the

den

ial

of

care

fro

m

a pro

vid

er w

ho is

not T

RIC

AR

Ea

uth

ori

zed.

When

ser

vic

es a

re d

enie

d b

ased

on m

edic

al

nec

essi

ty o

r a

ben

efit

dec

isio

n, you a

re

auto

mat

icall

y n

oti

fied

in w

riti

ng. T

he

noti

fica

tion i

ncl

udes

an e

xpla

nat

ion o

f w

hat

was

den

ied o

r w

hy a

pay

men

t w

as r

educe

d

and t

he

reas

on

ing b

ehin

d t

he

dec

isio

n.

Fil

ing

TR

ICA

RE F

or

Lif

e A

pp

eals

TF

L a

pp

eals

must

be

file

d w

ith W

PS

wit

hin

90 d

ays

from

the

dat

e th

at a

pp

ears

on t

he

expla

nat

ion o

f b

enefi

ts o

r den

ial

noti

fica

tion l

ette

r. I

f you a

re n

ot

sati

sfied

wit

h a

dec

isio

n r

ender

ed o

n a

n a

pp

eal,

ther

e m

ay b

e fu

rther

lev

els

of

app

eal

avail

able

to y

ou. Y

ou

r T

FL

app

eal

must

mee

t th

e re

qu

irem

ents

lis

ted i

n F

igu

re 7

.1

on

the

foll

ow

ing

pag

e. F

or

speci

fic

info

rmat

ion a

bout

fili

ng a

TF

L a

pp

eal,

conta

ct W

PS

.

Pri

or

auth

ori

zati

on d

enia

l ap

pea

ls m

ay b

e

eith

er e

xped

ited

or

none

xped

ited

, dep

endin

g

on t

he

urg

ency

of

the

situ

atio

n. Y

ou o

r an

appoin

ted r

epre

senta

tive

must

file

for

an

exp

edit

ed r

evie

w o

f a

pri

or

auth

ori

zati

on

den

ial w

ith

in t

hre

e ca

lend

ar

day

s of

rece

ipt

of

the

init

ial den

ial.

A n

one

xped

ited

den

ial

revie

w m

ust

be

file

d n

o l

ater

than 9

0 d

ays

aft

er r

ecei

pt

of

the

init

ial

den

ial.

27

Cer

tifi

cate

s m

ay b

e is

sued

in t

he

foll

ow

ing

circ

um

stance

s:

• U

pon t

he

sponso

r’s

separa

tion f

rom

act

ive

duty

, a

cert

ifica

te i

s is

sued

to t

he

sponso

r

list

ing a

ll e

lig

ible

fam

ily m

emb

ers.

• U

pon the

loss

of

elig

ibil

ity for

a dep

enden

t

chil

d (

age

21, or

age

23 i

f en

roll

ed i

n a

full

tim

e co

urs

e of

stu

dy

at

an a

ppro

ved

inst

itu

tio

n o

f h

igh

er l

earn

ing, a

nd i

f th

e

spo

nso

r pro

vid

es o

ver

50 p

erce

nt

of

the

fin

an

cia

l su

pport

), a

cer

tifi

cate

is

issu

ed

to t

he

dep

enden

t ch

ild.

• U

pon l

oss

of

cover

age

aft

er d

ivorc

e, a

cert

ifica

te i

s is

sued

to t

he

form

er s

pouse

once

in

form

atio

n i

s up

dat

ed i

n D

EE

RS

.

Cer

tifi

cate

s au

tom

atic

all

y r

eflec

t th

e m

ost

rece

nt

per

iod o

f co

nti

nuous

cover

age

under

TR

ICA

RE

. C

erti

fica

tes

issu

ed u

pon a

ben

efici

ary

req

ues

t re

flec

t ea

ch p

erio

d o

f

conti

nuous

TR

ICA

RE

cover

age

that

ended

wit

hin

the

24 m

onth

s pri

or

to t

he

dat

e of

loss

of

elig

ibil

ity.

Eac

h c

erti

fica

te iden

tifi

es

the

nam

e of

the

sponso

r or

fam

ily m

ember

it i

s is

sued

for,

the

dat

es T

RIC

AR

E

cover

age

beg

an a

nd e

nded

, and t

he

cert

ifica

te i

ssue

dat

e.

Sen

d w

ritt

en r

eques

ts f

or

cert

ifica

tes

of

cred

itab

le c

over

age

to:

Def

ense

Manpow

er D

ata

Cen

ter

Support

Offi

ce

AT

TN

: C

erti

fica

te o

f

Cre

dit

able

Cover

age

40

0 G

igli

ng R

oad

Sea

side,

CA

93955

6771

The

reques

t m

ust

incl

ude:

• S

ponso

r’s

nam

e and S

SN

or

DB

N

• N

am

e of

per

son t

he

cert

ifica

te i

s

reques

ted f

or

• R

easo

n f

or

the

reques

t

• N

am

e of

per

son a

nd a

dd

ress

the

cert

ifica

te s

hou

ld b

e se

nt

to

• R

eques

ter’

s si

gnat

ure

Cer

tifi

cate

s ca

nnot

be

reques

ted b

y p

hone.

If t

her

e is

an u

rgen

t nee

d f

or

a ce

rtifi

cate

of

cred

itab

le c

over

age,

fax y

ou

r re

ques

t

to 1

8316

55

8317

and

/or

reques

t th

at t

he

cert

ifica

te b

e fa

xed

to a

part

icu

lar

nu

mb

er.

Suspensio

n o

f Socia

l Securit

y

Dis

abilit

y Insura

nce

Med

icare

cover

age

may

conti

nue

up t

o

eig

ht

yea

rs a

nd s

ix m

onth

s fo

llow

ing

susp

ensi

on o

f S

oci

al

Sec

uri

ty D

isab

ilit

y

Insu

rance

pay

men

ts. W

hen

So

cial S

ecu

rity

Dis

abil

ity I

nsu

rance

pay

men

ts a

re s

usp

ended

bec

ause

you h

ave

retu

rned

to w

ork

, you

wil

l re

ceiv

e quart

erly

bil

ls f

or

the

Med

icare

Part

B p

rem

ium

. A

s lo

ng a

s you r

emain

enti

tled

to p

rem

ium

fre

e M

edic

are

Part

A,

you m

ust

pay

the

Part

B p

rem

ium

to

main

tain

you

r T

RIC

AR

E c

over

age.

SECTION 6

LIFE CHANGES: UPDATE YOUR DEERS RECORD

6

Med

icare

En

titl

em

en

t B

ased

on

Ag

e

The

Med

icare

enti

tlem

ent

age

is 6

5. If

you

alr

eady r

ecei

ve

ben

efits

fro

m t

he

SS

A o

r

the

Rail

road

Ret

irem

ent

Board

, you w

ill

auto

mat

ical

ly r

ecei

ve

Part

A a

nd b

e en

roll

ed

in P

art

B a

t ag

e 65.

If y

ou a

re a

ge

65 o

r old

er a

nd d

o n

ot re

ceiv

e

So

cial

Sec

uri

ty o

r R

ail

road

Ret

irem

ent

Board

ben

efits

, you m

ust

apply

for

Med

icare

ben

efits

. Y

ou

r M

edic

are

in

itia

l en

roll

men

t

per

iod i

s a

seven

month

per

iod.

• If

you

r bir

thd

ay f

all

s on t

he

firs

t of

the

month

, you

r in

itia

l en

roll

men

t p

erio

d

beg

ins

fou

r m

onth

s bef

ore

the

month

you

turn

65. E

nro

ll n

o l

ater

than t

wo m

onth

s

bef

ore

the

month

you t

urn

65 t

o a

void

a

bre

ak i

n T

RIC

AR

E c

over

age.

You a

re

elig

ible

for

Med

icare

cover

age

on t

he

firs

t

day

of

the

month

bef

ore

you t

urn

65.

• If

you

r bir

thd

ay f

all

s on a

ny d

ay o

ther

than t

he

firs

t of

the

month

, you

r in

itia

l

enro

llm

ent

per

iod b

egin

s th

ree

month

s

bef

ore

the

month

you t

urn

65.

En

roll

no

late

r th

an o

ne

month

bef

ore

you

r bir

th

month

to a

void

a b

reak i

n T

RIC

AR

E

cover

age.

You a

re e

lig

ible

for

Med

icare

on t

he

firs

t d

ay o

f th

e m

onth

you t

urn

65.

En

roll

in

Med

ica

re P

art

B w

hen

firs

t

elig

ible

to a

void

a b

rea

k i

n T

RIC

AR

E

cover

age.

If

you s

ign u

p a

fter

you

r in

itia

l

enro

llm

ent

per

iod

, you m

ay h

ave

to p

ay a

pre

miu

m s

urc

harg

e fo

r as

long a

s you h

ave

Part

B. T

he

Med

icare

Part

B s

urc

harg

e is

10 p

erce

nt fo

r ea

ch 1

2m

onth

per

iod that

you

wer

e el

igib

le to e

nro

ll i

n P

art

B b

ut d

id n

ot.

You

r P

art

B p

rem

ium

s are

auto

mat

icall

y

taken

out

of

you

r S

oci

al

Secu

rity

or

Rail

road

Ret

irem

ent

Board

chec

ks.

If

you

are

not

rece

ivin

g t

hes

e ty

pes

of

pay

men

ts,

Med

icare

bil

ls y

ou e

ver

y t

hre

e m

onth

s fo

r

Part

B p

rem

ium

s.

Frequentl

y A

sked Q

uesti

ons:

Medic

are

I w

ill

be

65 s

oon

an

d w

ill

bec

om

e en

titl

ed

to M

edic

are

. I

work

fu

ll t

ime

an

d h

ave

emp

loyer

gro

up

hea

lth

pla

n c

over

age,

an

d I

don

’t p

lan

on

ret

irin

g f

or

a f

ew

more

yea

rs. M

edic

are

says

I ca

n d

elay

my P

art

B e

nro

llm

ent

if I

have

emp

loyer

gro

up

hea

lth

pla

n c

over

age.

How

does

this

aff

ect

my T

RIC

AR

E b

enefi

t?

Med

icare

all

ow

s in

div

iduals

wit

h g

roup

hea

lth p

lan c

over

age

bas

ed o

n c

urr

ent

emplo

ym

ent

to d

elay

Part

B e

nro

llm

ent

and

sig

n u

p d

uri

ng a

sp

ecia

l en

roll

men

t p

erio

d,

wh

ich w

aiv

es t

he

late

en

roll

men

t pre

miu

m

surc

harg

e. I

f you o

r you

r sp

ouse

sti

ll w

ork

s

and h

as g

roup h

ealt

h p

lan c

over

age

thro

ugh

curr

ent

emplo

ym

ent,

you m

ay s

ign u

p

for

Med

icare

Part

B d

uri

ng t

he

spec

ial

enro

llm

ent

per

iod

, w

hic

h i

s av

ail

able

wit

hin

the

eig

ht

month

s fo

llow

ing e

ither

(1)

reti

rem

ent

or

(2)

the

end o

f th

e g

roup

hea

lth p

lan c

over

age,

wh

ichev

er c

om

es fi

rst.

If y

ou a

re e

nti

tled

to p

rem

ium

fre

e M

edic

are

Part

A, y

ou m

ust

als

o h

ave

Part

B to r

emain

TR

ICA

RE

eli

gib

le, ev

en i

f you h

ave

gro

up

hea

lth p

lan c

over

age

bas

ed o

n c

urr

ent

emplo

ym

ent.

Sig

n u

p f

or

Part

B b

efore

you

reti

re o

r lo

se g

roup h

ealt

h p

lan c

over

age

to

ensu

re y

ou

r T

RIC

AR

E c

over

age

under

TF

L

wil

l beg

in im

med

iate

ly foll

ow

ing the

end o

f

you

r g

roup h

ealt

h p

lan c

over

age.

You

r T

FL

cover

age

beg

ins

on t

he

firs

t d

ay y

ou h

ave

both

Med

icare

Part

A a

nd P

art

B c

over

age.

7

If I

am

not

enti

tled

to p

rem

ium

fre

e

Med

ica

re P

art

A w

hen

I t

urn

65, ca

n

I st

ill

use

TF

L?

Bec

ause

you a

re n

ot

enti

tled

to p

rem

ium

free

Med

icare

Part

A, you d

o n

ot

nee

d

Med

icare

Part

B t

o k

eep y

ou

r T

RIC

AR

E

ben

efit.

You d

o n

ot

transi

tion t

o T

FL

. Y

ou

may

conti

nue

enro

llm

ent

in T

RIC

AR

E

Pri

me

if y

ou liv

e in

a P

SA

, or

use

TR

ICA

RE

Sta

nd

ard

and T

RIC

AR

E E

xtr

a. F

or

info

rmat

ion a

bout

TR

ICA

RE

pro

gra

m

opti

ons,

vis

it t

he

TR

ICA

RE

Web

sit

e at

ww

w.t

ric

are

.mil

.

If y

ou a

re n

ot

elig

ible

for

pre

miu

mf

ree

Med

icare

Part

A u

nder

you

r ow

n S

SN

when

you t

urn

65, you m

ust

file

for

ben

efits

under

you

r sp

ouse

’s (

this

in

clu

des

div

orc

ed

or

dec

ease

d s

pou

ses)

SS

N i

f he

or

she

is

62 o

r old

er. If

you

r sp

ouse

is

not

yet

62

,

you m

ust

file

for

ben

efits

under

his

or

her

SS

N w

hen

he

or

she

turn

s 62.

If y

ou w

ill

be

elig

ible

under

you

r sp

ouse

’s

SS

N i

n t

he

futu

re, you s

hou

ld s

ign u

p

for

Med

icare

Part

B d

uri

ng y

ou

r in

itia

l

enro

llm

ent

per

iod t

o a

void

pay

ing a

Part

B

pre

miu

m s

urc

harg

e fo

r la

te e

nro

llm

ent.

Even

if

you a

re n

ot

enti

tled

to p

rem

ium

free

Med

icare

Part

A, you a

re e

lig

ible

for

Part

B a

t ag

e 65.

See

“M

edic

are

Enti

tlem

ent

Bas

ed o

n A

ge”

earl

ier

in t

his

sec

tion f

or

more

in

form

atio

n.

If y

ou s

ign u

p f

or

Med

icare

and a

re n

ot

elig

ible

for

pre

miu

mf

ree

Part

A u

nder

you

r or

you

r sp

ouse

’s (

this

in

clu

des

div

orc

ed o

r d

ecea

sed s

pou

ses)

SS

N, you

rece

ive

a “N

oti

ce o

f A

ward

” or

“Noti

ce

of

Dis

appro

ved

Cla

im”

from

SS

A. T

o

kee

p y

ou

r T

RIC

AR

E c

over

age,

take

the

“Noti

ce(s

) of

Aw

ard

” or

“Noti

ce(s

) of

Dis

appro

ved

Cla

im”

to a

un

iform

ed

serv

ices

iden

tifi

cati

on (

ID)

card

iss

uin

g

faci

lity

to h

ave

you

r D

efen

se E

nro

llm

ent

Eli

gib

ilit

y R

eport

ing S

yst

em (

DE

ER

S)

reco

rd u

pd

ated

and r

ecei

ve

a new

ID

card

.

Th

is a

llow

s you t

o k

eep y

ou

r el

igib

ilit

y f

or

TR

ICA

RE

Pri

me

or

TR

ICA

RE

Sta

nd

ard

and T

RIC

AR

E E

xtr

a aft

er y

ou t

urn

65.

To c

on

firm

that

you

r T

RIC

AR

E c

over

age

wil

l co

nti

nue

wit

hout

a bre

ak

, co

nta

ct

Wis

consi

n P

hysi

cians

Ser

vic

e (W

PS

)

aft

er y

ou u

pd

ate

you

r D

EE

RS

rec

ord

.

Note

: A

Rep

ort

of

Co

nfi

den

tia

l S

oci

al

Sec

uri

ty B

enefi

t In

form

ati

on (

SS

A2

458)

from

the

SS

A i

s not

acce

pte

d a

s pro

of

of

none

nti

tlem

ent

to p

rem

ium

fre

e P

art

A

to k

eep T

RIC

AR

E e

lig

ibil

ity.

How

TR

ICA

RE F

or L

ife W

ork

s

wit

h M

edic

are

Med

icare

and T

FL

work

toget

her

to

min

imiz

e you

r out

of

po

cket

exp

ense

s.

How

ever

, th

ere

are

inst

ance

s w

hen

som

e

hea

lth c

are

cost

s m

ay n

ot

be

cover

ed b

y

Med

icare

and

/or

TF

L.

Healt

h C

are

Serv

ices C

overe

d b

y

Med

icare

an

d T

RIC

AR

E

When

you s

ee a

part

icip

atin

g o

r

nonpart

icip

atin

g M

edic

are

pro

vid

er, you

hav

e no o

ut

of

po

cket

cost

s fo

r se

rvic

es

cover

ed b

y b

oth

Med

icare

and T

FL

. M

ost

hea

lth c

are

ser

vic

es f

all

into

th

is c

ateg

ory

.

Aft

er M

edic

are

pay

s it

s port

ion o

f th

e cl

aim

,

TF

L p

ays

the

rem

ain

ing a

mou

nt

and y

ou

pay

noth

ing.

As

the

pri

mary

pay

er, M

edic

are

appro

ves

hea

lth c

are

serv

ices

for

pay

men

t. I

f M

edic

are

SECTION 1


26

Children

You

r dep

enden

t’s

cover

age

do

es n

ot

change

bec

ause

you a

re e

nti

tled

to T

FL

.

Any c

hil

dre

n w

ho r

etain

eli

gib

ilit

y u

nder

the

sponso

r re

main

TR

ICA

RE

eli

gib

le

unti

l re

ach

ing a

ge

21 (

or

age

23 i

f en

roll

ed

in a

full

tim

e co

urs

e of st

udy

at an a

ppro

ved

inst

itu

tio

n o

f h

igh

er l

earn

ing, a

nd i

f th

e

spo

nso

r pro

vid

es o

ver

50 p

erce

nt

of

the

fin

an

cia

l su

pport

), a

s lo

ng a

s h

is o

r

her

DE

ER

S i

nfo

rmat

ion i

s cu

rren

t. T

o

exte

nd c

over

age

bey

ond y

ou

r ch

ild’s

21s

t

bir

thd

ay, co

nta

ct D

EE

RS

to v

erif

y w

hat

do

cum

enta

tion i

s nee

ded

.

At

age

21 (

or

23),

adu

lt c

hil

dre

n m

ay

be

elig

ible

for

the

TR

ICA

RE

You

ng

Adu

lt (

TY

A)

pro

gra

m, and l

ater

for

the

Conti

nued

Hea

lth C

are

Ben

efit

Pro

gra

m

(CH

CB

P).

For

more

in

form

atio

n o

n

TY

A, vis

it w

ww

.tric

are

.mil

/tya. F

or

more

in

form

atio

n o

n C

HC

BP,

vis

it

ww

w.t

ric

are

.mil

/ch

cbp

.

Note

: C

hil

dre

n w

ith d

isab

ilit

ies

may

rem

ain

TR

ICA

RE

eli

gib

le b

eyond t

he

norm

al

age

lim

its.

Conta

ct t

he

DE

ER

S S

upport

Offi

ce

for

elig

ibil

ity c

rite

ria.

Movin

g

Whet

her

you a

re m

ovin

g a

cross

the

stre

et

or

over

seas

, m

ovin

g w

ith T

FL

is

easy

.

Just

up

dat

e you

r p

erso

nal

info

rmat

ion i

n

DE

ER

S, fi

nd a

pro

vid

er w

ho i

s M

edic

are

cert

ified

(in

th

e U

nit

ed S

tate

s a

nd U

.S.

terr

itori

es [

Am

eric

an S

am

oa,

Guam

,

the

Nort

her

n M

ari

ana

Isla

nds,

Puer

to

Ric

o, and t

he

U.S

. V

irg

in I

slands]

) and

TR

ICA

RE

auth

ori

zed

, and c

onti

nue

to r

ecei

ve

care

when

you n

eed i

t. S

ee

“Fin

din

g a

Pro

vid

er”

in t

he

Get

ting C

are

sect

ion o

f th

is h

andbook.

Surviv

or C

overa

ge

If y

ou

r T

FL

sponso

r d

ies,

you r

emain

TR

ICA

RE

eli

gib

le a

nd w

ill

conti

nue

to

rece

ive

TF

L b

enefi

ts a

s lo

ng a

s yo

ur

DE

ER

S

info

rmat

ion is

up t

o d

ate

and y

ou a

re e

ither

of

the

foll

ow

ing:

• A

su

rviv

ing s

pouse

and d

o n

ot

rem

arr

y

(If

you r

emarr

y, T

RIC

AR

E e

ligib

ilit

y

can

not

be

rega

ined

la

ter,

eve

n i

f yo

u

div

orc

e or

your

new

spou

se d

ies.

)

• A

n u

nm

arr

ied c

hil

d u

nder

age

21 (

or

age

23 i

f en

roll

ed i

n a

full

tim

e co

urs

e of

stu

dy

at a

n a

ppro

ved in

stit

uti

on o

f h

igh

er

learn

ing, a

nd if th

e sp

onso

r pro

vided

ove

r

50 p

erce

nt

of

the

fin

an

cia

l su

pport

)

Note

: C

hil

dre

n w

ith d

isab

ilit

ies

may

rem

ain

TR

ICA

RE

eli

gib

le b

eyond n

orm

al

age

lim

its.

Conta

ct t

he

DE

ER

S S

upport

Offi

ce

for

elig

ibil

ity c

rite

ria.

Upon t

he

dea

th o

f you

r sp

onso

r, y

ou w

ill

rece

ive

a le

tter

fro

m D

EE

RS

tel

ling y

ou

about

you

r pro

gra

m o

pti

ons

and h

ow

you

r

ben

efits

wil

l ev

entu

all

y c

hange.

If

you h

ave

any q

ues

tions,

vis

it w

ww

.tri

care

.mil

/dee

rs.

Loss o

f Eligib

ilit

y

Upon l

oss

of

TR

ICA

RE

eli

gib

ilit

y, e

ach

fam

ily m

emb

er a

uto

mat

icall

y r

ecei

ves

a

cert

ifica

te o

f cr

edit

able

cover

age.

The

cert

ifica

te o

f cr

edit

able

cover

age

is a

do

cum

ent

that

ser

ves

as

evid

ence

of

pri

or

hea

lth c

are

cover

age

under

TR

ICA

RE

so

that

you c

an

not

be

excl

uded

fro

m a

new

hea

lth p

lan f

or

pre

exis

ting c

ond

itio

ns.

25

Gett

ing M

arrie

d o

r D

ivorced

Marr

iag

e

It i

s ex

trem

ely i

mport

ant

for

sponso

rs t

o

reg

iste

r new

spouse

s in

DE

ER

S t

o e

nsu

re

they

are

eli

gib

le f

or

TR

ICA

RE

pro

gra

ms,

incl

ud

ing T

FL

. T

o r

egis

ter

a new

spouse

in D

EE

RS

, th

e sp

onso

r nee

ds

to p

rovid

e a

copy o

f th

e m

arri

age

cert

ifica

te to

the

nea

rest

un

iform

ed s

ervic

es I

D c

ard

iss

uin

g f

acil

ity.

The

new

spouse

is

als

o r

equ

ired

to s

how

two f

orm

s of

ID (

e.g

., a

ny

com

bin

ati

on

of

So

cia

l Sec

uri

ty c

ard

, dri

ver’

s li

cen

se,

bir

th c

erti

fica

te, cu

rren

t m

ilit

ary

ID

card

,

or

CA

C).

Once

you

r sp

ouse

is

reg

iste

red

in D

EE

RS

, he

or

she

rece

ives

a u

nif

orm

ed

serv

ices

ID

card

and i

s el

igib

le f

or

TF

L.

You

r sp

ouse

must

show

his

or

her

ID

card

to a

cces

s ca

re.

Div

orc

e

Sponso

rs m

ust

up

dat

e D

EE

RS

in t

he

even

t

of

a d

ivorc

e. T

he

sponso

r nee

ds

to p

rovid

e

a co

py o

f th

e d

ivorc

e dec

ree,

dis

solu

tion,

or

an

nu

lmen

t.

Fo

rmer

Sp

ou

se C

overa

ge

Cer

tain

form

er s

pouse

s are

eli

gib

le t

o

conti

nue

TF

L c

over

age

as l

ong a

s th

ey:

• D

o n

ot

rem

arr

y (

If a

form

er s

pou

se

rem

arr

ies,

th

e lo

ss o

f ben

efits

rem

ain

s

appli

cable

eve

n i

f th

e re

marr

iage

end

s

in d

eath

or

div

orc

e.)

• A

re n

ot

cover

ed b

y e

mplo

yer

sponso

red

hea

lth p

lans

• A

re n

ot

als

o f

orm

er s

pouse

s of

Nort

h

Atl

anti

c T

reat

y O

rgan

izat

ion o

r P

art

ner

s

for

Pea

ce n

atio

n m

emb

ers

• M

eet

the

requ

irem

ents

of

one

of

the

two

situ

atio

ns

des

crib

ed i

n F

igu

re 6

.1

Form

er s

pouse

s w

ho a

re T

FL

eli

gib

le m

ust

change

thei

r p

erso

nal

info

rmat

ion i

n

DE

ER

S s

o t

hei

r nam

e and S

oci

al

Sec

uri

ty

nu

mb

er (

SS

N)

or

DoD

Ben

efits

Nu

mb

er

(DB

N)

are

lis

ted f

or

the

pri

mary

conta

ct

info

rmat

ion. T

he

form

er s

pouse

’s T

RIC

AR

E

elig

ibil

ity i

s sh

ow

n i

n D

EE

RS

under

his

or

her

SS

N o

r D

BN

, not

the

sponso

r’s.

Eli

gib

ilit

y R

equ

irem

ents

fo

r F

orm

er S

pou

ses

Fig

ure

6.1

1•

The

form

er s

pouse

must

hav

e bee

n m

arr

ied to the

sam

e m

ilit

ary

mem

ber

or

form

er m

ember

for

at lea

st 2

0 y

ears

, an

d a

t le

ast

20 o

f th

ose

yea

rs m

ust

hav

e bee

n c

redit

able

in d

eter

min

ing

the

mem

ber

’s e

lig

ibil

ity

for

reti

rem

ent

pay

.

• T

he

form

er s

pouse

is

elig

ible

for

TR

ICA

RE

cover

age

aft

er t

he

dat

e of

the

div

orc

e,

dis

solu

tion,

or

an

nu

lmen

t.1

• E

lig

ibil

ity

conti

nues

as

long

as

the

pre

ced

ing

req

uir

emen

ts c

onti

nue

to b

e m

et a

nd

the

form

er s

pouse

do

es n

ot

rem

arr

y.

2•

The

form

er s

pouse

must

hav

e b

een

marr

ied

to

the

sam

e m

ilit

ary

mem

ber

or

form

er

mem

ber

for

at l

east

20

yea

rs,

and

at

leas

t 15

—but

less

than

20

—of

those

marr

ied

yea

rs

must

hav

e b

een

cre

dit

able

in

det

erm

inin

g t

he

mem

ber

’s e

lig

ibil

ity

for

reti

rem

ent

pay

.

• T

he

form

er s

pouse

is

elig

ible

for

TR

ICA

RE

cover

age

for

on

ly o

ne

yea

r fr

om

the

dat

e of

the

div

orc

e.

1. F

or

div

orc

e d

ecre

es, d

isso

luti

on

s, o

r a

nn

ulm

en

ts o

n o

r b

efore

Sep

tem

ber

29, 19

88

, co

nta

ct D

EE

RS f

or

elig

ibil

ity

veri

fica

tio

n.

SECTION 6

LIFE CHANGES: UPDATE YOUR DEERS RECORD

8

do

es n

ot

pay

bec

ause

it

det

erm

ines

that

the

care

is n

ot m

edic

ally

nec

essa

ry, T

FL

als

o d

oes

not p

ay. Y

ou m

ay a

ppea

l Med

icar

e’s

dec

isio

n,

and i

f M

edic

are

rec

onsi

der

s and p

rovid

es

cover

age,

TF

L a

lso r

econsi

der

s co

ver

age.

If a

hea

lth c

are

ser

vic

e is

cover

ed b

y b

oth

Med

icare

and T

FL

, but

Med

icare

do

es n

ot

pay

bec

ause

you h

ave

use

d u

p y

our

Med

icar

e

ben

efit,

TF

L b

ecom

es t

he

pri

mary

pay

er. In

this

cas

e, y

ou a

re r

esponsi

ble

for

you

r T

FL

ded

uct

ible

and c

ost

share

s.

If a

hea

lth c

are

ser

vic

e is

norm

all

y c

over

ed

by b

oth

Med

icare

and T

FL

, but you r

ecei

ve

the

serv

ice

from

a p

rovid

er w

ho h

as o

pte

d

out

of

Med

icare

, th

e pro

vid

er c

an

not

bil

l

Med

icare

and

, ther

efore

, Med

icare

wil

l pay

noth

ing. W

hen

you s

ee a

n o

pt

out pro

vid

er,

TF

L w

ill

pro

cess

the

claim

as

the

seco

nd

pay

er, u

nle

ss y

ou h

ave

oth

er h

ealt

h insu

rance

(OH

I). T

FL

pay

s th

e am

ou

nt

it w

ou

ld h

ave

paid

if

Med

icare

had

pro

cess

ed t

he

claim

(norm

all

y 2

0 p

erce

nt

of

the

TR

ICA

RE

all

ow

able

ch

arg

e) a

nd y

ou a

re r

esponsi

ble

for

the

rem

ain

der

of

the

bil

led c

harg

es.

Opt

out pro

vid

ers

esta

bli

sh p

rivat

e co

ntr

acts

wit

h p

atie

nts

. Under

a p

rivat

e co

ntr

act,

ther

e

are

no lim

its

on w

hat

the

pro

vid

er c

an c

har

ge

for

hea

lth c

are

ser

vic

es.

Healt

h C

are

Serv

ices C

overe

d b

y

Med

icare

bu

t N

ot

by T

RIC

AR

E

When

you r

ecei

ve

care

that

is

cover

ed

by M

edic

are

on

ly (

e.g., c

hir

opra

ctic

care

),

Med

icar

e pro

cess

es the

clai

m a

s th

e pri

mar

y

pay

er. T

FL

makes

no p

aym

ent,

reg

ard

less

of

any a

ctio

n M

edic

are

takes

. Y

ou a

re

resp

onsi

ble

for

the

Med

icare

ded

uct

ible

and c

opay

men

ts.

Healt

h C

are

Serv

ices C

overe

d b

y

TR

ICA

RE b

ut

No

t b

y M

ed

icare

When

you r

ecei

ve

care

that

is

cover

ed

on

ly b

y T

FL

(e.g

., T

RIC

AR

Ec

ove

red

serv

ices

rec

eive

d o

vers

eas)

, T

RIC

AR

E

pro

cess

es t

he

claim

as

the

pri

mary

pay

er.

You a

re r

esponsi

ble

for

the

appli

cable

TF

L

ded

uct

ible

, co

sts

hare

s, a

nd r

emain

ing

bil

led c

harg

es.

TF

L c

laim

s ar

e norm

ally

file

d w

ith M

edic

are

firs

t; h

ow

ever

, w

hen

a h

ealt

h c

are

ser

vic

e is

not co

ver

ed b

y M

edic

are

, you

r pro

vid

er m

ay

file

the

claim

dir

ectl

y w

ith W

PS

, u

nle

ss

you h

ave

OH

I. S

ee t

he

Cla

ims

sect

ion o

f

this

handbook f

or

add

itio

nal

info

rmat

ion.

Healt

h C

are

Serv

ices N

ot

Co

vere

d

by M

ed

icare

or

TR

ICA

RE

When

you r

ecei

ve

care

that

is

not

cover

ed

by M

edic

are

or

TF

L (e.

g., c

osm

etic

surg

ery)

,

nei

ther

makes

a p

aym

ent

on t

he

claim

. Y

ou

are

res

ponsi

ble

for

the

enti

re b

ill.

For

more

in

form

atio

n o

n c

over

ed

serv

ices

, vis

it w

ww

.med

ica

re.g

ov

or

ww

w.t

rica

re.m

il o

r co

nta

ct W

PS

.

See

Fig

ure

1.1

on t

he

foll

owin

g p

age

for

TF

L o

ut

of

pock

et c

ost

s.

9

Co

ord

inati

ng

TR

ICA

RE F

or

Lif

e w

ith

O

ther

Healt

h I

nsu

ran

ce

How

Med

icare

coord

inat

es w

ith O

HI

dep

ends

on w

het

her

or

not

the

OH

I is

bas

ed o

n c

urr

ent

emplo

ym

ent.

In e

ither

case

, T

FL

is

the

last

pay

er.

OH

I N

ot

Base

d o

n C

urr

en

t Em

plo

ym

en

t

If y

ou h

ave

OH

I th

at i

s not

bas

ed o

n y

ou

r

or

a fa

mil

y m

emb

er’s

cu

rren

t em

plo

ym

ent,

Med

icare

pay

s fi

rst,

the

OH

I pay

s se

cond

,

and T

FL

pay

s la

st.

OH

I B

ase

d o

n C

urr

en

t Em

plo

ym

en

t

Gen

erall

y, i

f you h

ave

an e

mplo

yer

sponso

red h

ealt

h p

lan b

ased

on c

urr

ent

emplo

ym

ent,

that

hea

lth p

lan p

ays

firs

t,

Med

icare

pay

s se

cond

, and T

FL

pay

s la

st.

If t

her

e are

few

er t

han

20 e

mplo

yee

s in

the

emplo

yer

sponso

red p

lan, M

edic

are

pay

s

firs

t, t

he

emplo

yer

pla

n p

ays

seco

nd

, and

TF

L p

ays

last

.

When

you

r O

HI

pro

cess

es t

he

claim

aft

er

Med

icare

, you n

eed t

o s

ubm

it a

cla

im t

o

WP

S f

or

any r

emain

ing b

ala

nce

. S

ee

the

Cla

ims

sect

ion o

f th

is h

andbook f

or

add

itio

nal

info

rmat

ion.

Note

: T

RIC

AR

E p

ays

aft

er m

ost

insu

rance

pla

ns

wit

h t

he

exce

pti

on o

f M

edic

aid

,

TR

ICA

RE

supple

men

ts, th

e In

dia

n H

ealt

h

Ser

vic

e, a

nd o

ther

pro

gra

ms

and p

lans

as

iden

tifi

ed b

y t

he

TR

ICA

RE

Manag

emen

t

Act

ivit

y.

Ho

w T

RIC

AR

E F

or

Lif

e W

ork

s O

vers

eas

Med

icare

pro

vid

es c

over

age

in t

he

Un

ited

Sta

tes

and U

.S. te

rrit

ori

es, w

hic

h a

re:

• A

mer

ican S

am

oa

• G

uam

• N

ort

her

n M

ari

ana

Isla

nds

• P

uer

to R

ico

• U

.S. V

irg

in I

slands

Med

icare

als

o c

over

s hea

lth c

are

ser

vic

es

rece

ived

on b

oard

sh

ips

in U

.S. te

rrit

ori

al

wat

ers.

In t

hes

e lo

cati

ons,

TF

L w

ork

s

exac

tly a

s it

do

es i

n t

he

Un

ited

Sta

tes.

Un

less

you h

ave

OH

I, T

FL

is

the

seco

nd

pay

er a

fter

Med

icare

for

most

hea

lth c

are

serv

ices

. Y

ou

r pro

vid

er fi

les

the

claim

wit

h M

edic

are

firs

t. M

edic

are

pay

s it

s

port

ion a

nd a

uto

mat

icall

y f

orw

ard

s th

e

claim

to W

PS

for

pro

cess

ing.

TR

ICA

RE

Fo

r L

ife

Ou

tof

Po

cket

Cost

s

Fig

ure

1.1

Typ

e o

f Serv

ice

Me

dic

are

Pays

TR

ICA

RE

Pays

Yo

u P

ay

Cover

ed b

y T

RIC

AR

E

an

d M

edic

are

Med

icare

auth

ori

zed

am

ou

nt

Rem

ain

ing

am

ou

nt

Noth

ing

Cover

ed b

y M

edic

are

on

lyM

edic

are

auth

ori

zed

am

ou

nt

Noth

ing

Med

icare

ded

uct

ible

and

cost

share

Cover

ed b

y T

RIC

AR

E

on

lyN

oth

ing

TR

ICA

RE

all

ow

able

am

ou

nt

TR

ICA

RE

ded

uct

ible

and

cost

share

Not

Cover

ed b

y

TR

ICA

RE

or

Med

ica

re

Noth

ing

Noth

ing

Bil

led c

harg

es (w

hic

h

ma

y ex

ceed

th

e

Med

icare

am

ou

nt

or

ba

lan

ceb

illi

ng

ca

p)

SECTION 1


24

Lif

e C

han

ges:

Up

date

Yo

ur

DEER

S R

eco

rd

TR

ICA

RE

For

Lif

e (T

FL

) co

nti

nues

to

pro

vid

e hea

lth c

are

cove

rage

for yo

u a

nd y

our

fam

ily a

s you

r li

fe c

hanges

. H

ow

ever

, you

nee

d t

o t

ake

spec

ific

acti

ons

to m

ake

sure

you r

emai

n T

RIC

AR

Ee

ligib

le. I

t is

ess

enti

al

that

you k

eep i

nfo

rmat

ion i

n t

he

Def

ense

En

roll

men

t E

lig

ibil

ity R

eport

ing S

yst

em

(DE

ER

S)

curr

ent

for

you a

nd y

ou

r fa

mil

y.

DE

ER

S i

s a

com

pute

rize

d d

atab

ase

of

un

iform

ed s

ervic

e m

emb

ers

(act

ive

du

ty

an

d r

etir

ed),

thei

r fa

mil

y m

emb

ers,

and

oth

ers

who a

re e

ligib

le f

or

mil

itary

ben

efits

,

incl

ud

ing T

RIC

AR

E. P

rop

er a

nd c

urr

ent

DE

ER

S r

egis

trat

ion i

s key

to r

ecei

vin

g

tim

ely,

eff

ecti

ve

TF

L b

enefi

ts.

Main

tain

ing y

ou

r T

RIC

AR

E e

lig

ibil

ity

is y

ou

r re

sponsi

bil

ity.

It

is e

ssen

tial

to

ver

ify y

ou

r in

form

atio

n i

n D

EE

RS

any

tim

e you h

ave

a li

fec

hang

ing e

ven

t.

You h

ave

sever

al

opti

ons

for

up

dat

ing

and v

erif

yin

g D

EE

RS

in

form

atio

n. S

ee

“Im

port

ant

Conta

ct I

nfo

rmat

ion”

at t

he

beg

inn

ing o

f th

is h

andbook.

Note

: O

nly

sponso

rs (

or

those

appoin

ted

pow

er o

f a

ttorn

ey)

can a

dd o

r del

ete

a

fam

ily m

ember

. F

am

ily m

ember

s ag

e 18

and o

lder

may

up

dat

e th

eir

ow

n c

onta

ct

info

rmat

ion

.

Usin

g m

ilConnect

to U

pdate

In

form

ati

on in D

EER

S

Act

ive

duty

ser

vic

e m

emb

ers,

ret

iree

s,

and e

lig

ible

fam

ily m

emb

ers

can u

se t

he

mil

Con

nec

t W

eb s

ite

to a

cces

s hea

lth

care

eli

gib

ilit

y a

nd p

erso

nnel

in

form

atio

n,

un

iform

ed s

ervic

es i

den

tifi

cati

on (

ID)

card

s and i

nfo

rmat

ion o

n o

ther

ben

efits

,

incl

ud

ing S

ervic

emem

ber

s’ G

roup

Lif

e In

sura

nce

.

You c

an l

og o

n t

o m

ilC

on

nec

t’s

secu

re

site

usi

ng a

Com

mon A

cces

s C

ard

(C

AC

),

Def

ense

Fin

ance

and A

ccou

nti

ng S

ervic

es

use

r nam

e and p

assw

ord

or

Dep

art

men

t

of

Def

ense

(D

oD

) S

elf

Ser

vic

e L

ogon

(DS

Logon)

. Y

ou m

ay v

isit

a T

RIC

AR

E

Ser

vic

e C

ente

r or

a V

eter

ans

Aff

air

s

Reg

ional

Offi

ce t

o c

om

ple

te a

n i

np

erso

n

pro

ofi

ng p

roce

ss t

o r

eques

t a

DS

Logon, or

you m

ay g

o o

nli

ne

for

a re

mote

pro

ofi

ng

pro

cess

. F

or

more

in

form

atio

n, vis

it

ww

w.d

md

c.osd

.mil

/id

enti

tym

an

agem

ent.

If y

ou n

eed a

new

ID

card

, you c

an v

isit

a u

nif

orm

ed s

ervic

es I

D c

ard

iss

uin

g

faci

lity

and r

eques

t a

DS

Logon a

t th

e

sam

e ti

me.

23

Thir

d-P

arty

Lia

bilit

y

If T

RIC

AR

E i

s th

e pri

mary

pay

er, th

e

Fed

eral M

edic

al C

are

Rec

over

y A

ct a

llow

s

TR

ICA

RE

to b

e re

imbu

rsed

for

trea

tmen

t

cost

s if

you a

re inju

red in a

n a

ccid

ent ca

use

d

by s

om

eone

else

. T

he

Sta

tem

ent of P

erso

nal

Inju

ry—

Poss

ible

Th

ird

Part

y L

iabil

ity

form

(D

D F

orm

2527)

is s

ent

to y

ou i

f a

claim

app

ears

to h

ave

thir

dp

art

y l

iabil

ity

involv

emen

t. W

ith

in 3

5 c

ale

nd

ar

day

s,

you m

ust

com

ple

te a

nd s

ign t

his

form

and f

oll

ow

the

dir

ecti

ons

for

retu

rnin

g i

t

to t

he

appro

pri

ate

claim

s pro

cess

or.

Vis

it

ww

w.t

ric

are

.mil

/cla

ims

to d

ow

nlo

ad

DD

Form

2527.

Expla

nati

on o

f B

enefi

ts

A T

RIC

AR

E E

OB

is

not

a bil

l. I

t is

an

item

ized

sta

tem

ent

that

show

s th

e ac

tion

TR

ICA

RE

has

taken

on y

ou

r cl

aim

s. A

n

EO

B i

s fo

r you

r in

form

atio

n a

nd fi

les.

Aft

er r

evie

win

g t

he

EO

B, you h

ave

the

rig

ht

to a

pp

eal

cert

ain

dec

isio

ns

regard

ing

you

r cl

aim

s and m

ust

do s

o i

n w

riti

ng

wit

hin

90 d

ays

of

the

dat

e of

the

EO

B

noti

ce. Y

ou s

hou

ld k

eep E

OB

s w

ith y

ou

r

hea

lth insu

rance

rec

ord

s fo

r fu

ture

ref

eren

ce.

For

more

in

form

atio

n a

bout

app

eals

, vis

it

ww

w.T

RIC

AR

E4u

.com

or

see

the

For

Info

rma

tio

n a

nd A

ssis

tan

ce s

ecti

on o

f

this

handbook.

Debt

Collecti

on

Assis

tance O

fficers

TR

ICA

RE

Deb

t C

oll

ecti

on A

ssis

tance

Offi

cers

(D

CA

Os)

are

loca

ted a

t M

TF

s an

d

TR

ICA

RE

Reg

ional

Offi

ces

to h

elp r

esolv

e

you

r T

RIC

AR

E h

ealt

h c

are

coll

ecti

on

rela

ted i

ssues

. C

onta

ct a

DC

AO

if

you

rece

ived

a n

egat

ive

cred

it r

atin

g o

r w

ere

conta

cted

by a

coll

ecti

on a

gen

cy d

ue

to

an i

ssue

rela

ted t

o y

ou

r T

FL

cla

im.

When

you

vis

it a

TR

ICA

RE

DC

AO

for

assi

stance

, you m

ust

take

or

subm

it

docu

men

tati

on a

ssoci

ated

wit

h a

coll

ecti

on

acti

on o

r ad

ver

se c

red

it r

atin

g, in

clud

ing

deb

t co

llec

tion l

ette

rs, E

OB

s, a

nd m

edic

al

and

/or

den

tal bil

ls f

rom

pro

vid

ers.

The

more

info

rmat

ion y

ou p

rovid

e, the

fast

er the

cause

of

the

pro

ble

m c

an b

e det

erm

ined

. T

he

DC

AO

res

earc

hes

you

r cl

aim

, pro

vid

es y

ou

wit

h a

wri

tten

res

olu

tion o

f you

r co

llec

tion

pro

ble

m, and in

form

s th

e co

llec

tion a

gen

cy

that

act

ion is

bei

ng tak

en to r

esolv

e th

e is

sue.

DC

AO

s ca

nnot

pro

vid

e le

gal

advic

e or

repair

you

r cr

edit

rat

ing, but

they

can

hel

p b

y p

rovid

ing d

ocu

men

tati

on f

or

the

coll

ecti

on o

r cr

editr

eport

ing a

gen

cy t

o

expla

in t

he

circ

um

stan

ces

rela

ting t

o t

he

deb

t. V

isit

the

DC

AO

dir

ecto

ry o

nli

ne

at w

ww

.tric

are

.mil

/bca

cdca

o t

o fi

nd a

TR

ICA

RE

DC

AO

nea

r you.

TR

ICA

RE

DC

AO

s ca

n o

nly

ass

ist yo

u w

ith

TF

Lr

elat

ed i

ssues

. C

onta

ct M

edic

are

for

assi

stance

wit

h M

edic

are

rel

ated

iss

ues

.

SECTION 5

CLAIMS

10

Med

icare

does

not

pro

vid

e co

ver

age

outs

ide

of

the

Un

ited

Sta

tes,

U.S

. te

rrit

ori

es, and

ship

s in

ter

rito

rial

wat

ers.

Ther

efore

, T

FL

is

you

r pri

mary

pay

er f

or

hea

lth c

are

rec

eived

in a

ll o

ther

over

seas

lo

cati

ons,

un

less

you

hav

e O

HI.

TF

L p

rovid

es t

he

sam

e co

ver

age

as T

RIC

AR

E S

tand

ard

and h

as t

he

sam

e

cost

share

s an

d d

educt

ible

s fo

r ben

efici

ari

es

who l

ive

or

trav

el o

ver

seas

. W

hen

see

kin

g

care

fro

m a

host

nat

ion p

rovid

er, re

gio

n

or

cou

ntr

ys

pec

ific

requ

irem

ents

may

als

o

apply

. You s

hould

be

pre

par

ed to

pay

up f

ront

for

serv

ices

and s

ubm

it a

cla

im t

o t

he

TR

ICA

RE

Over

seas

Pro

gra

m (

TO

P)

claim

s pro

cess

or.

Cla

ims

for

care

rec

eived

over

seas

are

subm

itte

d d

irec

tly t

o t

he

TO

P c

laim

spro

cess

ing a

dd

ress

for

the

reg

ion w

her

e you r

ecei

ved

care

. S

ee t

he

Cla

ims

sect

ion o

f th

is h

andbook f

or

more

info

rmat

ion.

Frequentl

y A

sked Q

uesti

ons:

How

TR

ICA

RE F

or L

ife W

ork

s

Does

TF

L p

ay f

or

the

Med

ica

re P

art

B

pre

miu

m a

nd

ded

uct

ible

?

The

Part

B m

onth

ly p

rem

ium

is

you

r

resp

onsi

bil

ity.

TF

L c

over

s th

e M

edic

are

Part

B d

educt

ible

as

long a

s th

e hea

lth

care

ser

vic

e is

cover

ed b

y b

oth

Med

icare

and T

RIC

AR

E.

Usi

ng T

FL

see

ms

so e

asy

. Sh

ou

ld I

can

cel

my M

edic

are

su

pp

lem

ent,

Med

ica

re

Ad

va

nta

ge

Pla

n, or

OH

I?

You s

hou

ld c

are

full

y e

valu

ate

you

r hea

lth

insu

rance

nee

ds

to d

eter

min

e if

you

shou

ld c

onti

nue

any O

HI

pla

ns,

Med

icare

supple

men

ts, and M

edic

are

Advanta

ge

Pla

ns.

You m

ay c

onta

ct y

ou

r lo

cal

Sta

te

11

Hea

lth I

nsu

rance

Ass

ista

nce

Pro

gra

m

for

free

hea

lth i

nsu

rance

cou

nse

ling

and a

ssis

tance

.

Note

: If

you d

rop y

ou

r O

HI

cover

age,

you

must

noti

fy W

PS

.

I a

m a

TF

L b

enefi

cia

ry a

nd

a r

etir

ed

fed

era

l em

plo

yee

. C

an

I s

usp

end

my

Fed

era

l E

mp

loyee

s H

ea

lth

Ben

efi

ts

(FE

HB

) p

rogra

m c

over

age

to u

se T

FL

?

Yes

. Y

ou m

ay s

usp

end y

ou

r F

EH

B

cover

age

and p

rem

ium

pay

men

ts a

t any

tim

e. V

isit

ww

w.o

pm

.gov/f

orm

s to

get

a

Hea

lth B

enefi

ts E

lect

ion F

orm

(S

F 2

80

9).

Eli

gib

le u

nre

marr

ied f

orm

er s

pouse

s ca

n

get

the

form

fro

m t

he

emplo

yin

g o

ffice

s

or

reti

rem

ent

syst

em m

ain

tain

ing t

hei

r

enro

llm

ents

.

Is a

ref

erra

l or

TR

ICA

RE

prio

r

au

thoriz

ati

on

req

uir

ed f

or

hea

lth

care

ser

vic

es?

A r

efer

ral or

TR

ICA

RE

pri

or

auth

ori

zati

on

is n

ot

requ

ired

under

TF

L w

hen

Med

icare

is t

he

pri

mary

pay

er. H

ow

ever

, w

hen

TF

L

bec

om

es t

he

pri

mary

pay

er, T

RIC

AR

E

auth

ori

zati

on r

equ

irem

ents

apply

as

they

would

for

a T

RIC

AR

E S

tandar

d b

enefi

ciar

y.

I w

as

enro

lled

in

TR

ICA

RE

Prim

e at

a m

ilit

ary t

reatm

ent

faci

lity

(M

TF

).

I re

ceiv

ed a

let

ter

from

th

e M

TF

tell

ing m

e I

wa

s n

o l

on

ger

eli

gib

le f

or

enro

llm

ent

in T

RIC

AR

E P

rim

e. W

hat

does

that

mea

n?

Once

you b

ecom

e en

titl

ed t

o p

rem

ium

fre

e

Med

icare

Part

A b

ecau

se y

ou a

re a

ge

65,

you a

re e

lig

ible

for

TF

L w

hen

you a

lso

hav

e M

edic

are

Part

B. Y

ou a

re n

o l

onger

elig

ible

for

enro

llm

ent

in T

RIC

AR

E P

rim

e,

un

less

you h

ave

an a

ctiv

e duty

sponso

r.

You m

ay c

onti

nue

to s

eek c

are

at

an M

TF

on a

spac

eav

ail

able

bas

is, but

wil

l li

kel

y

nee

d t

o s

eek c

are

fro

m c

ivil

ian M

edic

are

pro

vid

ers.

When

you v

isit

civ

ilia

n M

edic

are

pro

vid

ers,

you h

ave

no o

ut

of

po

cket

cost

s

for

serv

ices

cover

ed b

y b

oth

Med

icare

and

TR

ICA

RE

. Conta

ct M

edic

are

for

assi

stan

ce

wit

h fi

nd

ing M

edic

are

cer

tifi

ed p

rovid

ers.

You m

ay b

e ab

le t

o s

ign u

p f

or

TR

ICA

RE

Plu

s. T

RIC

AR

E P

lus

is a

pro

gra

m t

hat

allo

ws

ben

efici

ari

es w

ho n

orm

ally

are

on

ly

able

to g

et M

TF

care

on a

spac

eav

ail

able

bas

is t

o e

nro

ll a

nd r

ecei

ve

pri

mary

care

appoin

tmen

ts a

t th

e M

TF

wit

hin

the

sam

e pri

mary

care

acc

ess

stand

ard

s as

ben

efici

ari

es e

nro

lled

in a

TR

ICA

RE

Pri

me

opti

on. B

enefi

ciari

es s

hould

conta

ct

thei

r lo

cal

MT

Fs

to d

eter

min

e if

they

may

part

icip

ate

in T

RIC

AR

E P

lus.

En

roll

men

t in

TR

ICA

RE

Plu

s at

one

MT

F

do

es n

ot

auto

mat

icall

y e

xte

nd T

RIC

AR

E

Plu

s en

roll

men

t to

anoth

er M

TF. T

he

MT

F

is n

ot

resp

onsi

ble

for

any c

ost

s w

hen

a

TR

ICA

RE

Plu

s en

roll

ee i

s re

ferr

ed o

uts

ide

the

MT

F f

or

add

itio

nal

civil

ian c

are

.

SECTION 1


22

Cla

ims

Healt

h C

are C

laim

s

In m

ost

cas

es, yo

ur

pro

vid

er fi

les

your

hea

lth

care

cla

ims

wit

h M

edic

are

firs

t. M

edic

are

pay

s it

s port

ion a

nd

, u

nle

ss y

ou h

ave

oth

er

hea

lth i

nsu

rance

(O

HI)

, fo

rward

s th

e cl

aim

to T

RIC

AR

E F

or

Lif

e (T

FL

) fo

r pro

cess

ing.

How

ever

, w

hen

TF

L i

s th

e pri

mary

pay

er

(e.g

., i

f M

edic

are

does

not

cove

r th

e h

ealt

h

care

ser

vice

), y

ou

r pro

vid

er m

ay b

e re

quir

ed

to fi

le y

ou

r cl

aim

dir

ectl

y w

ith W

isco

nsi

n

Physi

cian

s S

ervic

e (W

PS

)/T

FL

. If

you h

ave

OH

I, y

ou m

ust

file

the

claim

wit

h y

ou

r O

HI

bef

ore

fili

ng w

ith T

FL

.

You a

re r

esponsi

ble

for

mak

ing s

ure

you

r cl

aim

s are

file

d w

ith

in o

ne

yea

r of

eith

er t

he

dat

e of

serv

ice

or

the

dat

e of

an i

npat

ient

dis

charg

e. T

o fi

le a

cla

im

wit

h T

FL

, fi

ll o

ut

a T

RIC

AR

E D

oD

/

CH

AM

PU

S M

edic

al

Cla

im—

Pa

tien

t’s

Req

ues

t fo

r M

edic

al

Pa

ymen

t fo

rm

(DD

Form

26

42)

. Y

ou c

an d

ow

nlo

ad

form

s and i

nst

ruct

ions

from

TR

ICA

RE

at w

ww

.tric

are

.mil

/cla

ims

or

the

WP

S

Web

sit

e at

ww

w.T

RIC

AR

E4u

.com

.

You c

an a

lso o

bta

in f

orm

s an

d i

nst

ruct

ions

at a

TR

ICA

RE

Ser

vic

e C

ente

r (T

SC

) or

a m

ilit

ary

tre

atm

ent

faci

lity

(M

TF

). F

ill

out

the

form

com

ple

tely

and s

ign i

t. V

isit

ww

w.t

ric

are

.mil

/con

tact

us

to l

oca

te a

TS

C o

r M

TF.

When

fili

ng a

cla

im w

ith T

FL

, in

clude

you

r M

edic

are

Su

mm

ary

Noti

ce a

nd O

HI

expla

nat

ion o

f ben

efits

(E

OB

), i

f ap

pli

cable

.

Att

ach a

rea

dab

le c

opy o

f th

e pro

vid

er’s

bil

l to

the

claim

form

, m

ak

ing s

ure

it

conta

ins

the

foll

ow

ing:

• P

atie

nt’s

nam

e

• S

ponso

r’s

So

cial

Sec

uri

ty n

um

ber

(S

SN

)

or

Dep

art

men

t of

Def

ense

Ben

efits

Nu

mb

er (

DB

N)

(Eli

gib

le f

orm

er s

pou

ses

shou

ld u

se t

hei

r ow

n S

SN

s or

DB

Ns,

not

thei

r sp

on

sors

’.)

• P

rovid

er’s

nam

e an

d a

dd

ress

(If

more

than

on

e pro

vid

er’s

na

me

is o

n t

he

bil

l, c

ircl

e

the

na

me

of

the

per

son w

ho p

rovi

ded

th

e

serv

ice

for

wh

ich t

he

cla

im i

s fi

led

.)

• D

ate

and p

lace

of

each

ser

vic

e

• D

escr

ipti

on o

f ea

ch s

ervic

e or

supply

fu

rnis

hed

• C

harg

e fo

r ea

ch s

ervic

e

• D

iag

nosi

s (I

f th

e dia

gn

osi

s is

not

on

the

bil

l, b

e su

re t

o c

om

ple

te b

lock

8a

on t

he

form

.)

Un

like

oth

er T

RIC

AR

E b

enefi

ciari

es, T

FL

ben

efici

arie

s sh

ould

file

cla

ims

in the

regio

ns

wher

e th

ey r

ecei

ved

care

. S

end c

laim

s to

the

appro

pri

ate

mail

ing a

dd

ress

pro

vid

ed

in “

Import

ant

Conta

ct I

nfo

rmat

ion”

at t

he

beg

inn

ing o

f th

is h

andbook.

Appealing a

Cla

im o

r

Auth

oriz

ati

on D

enia

l

You m

ay a

pp

eal

auth

ori

zati

on d

enia

ls o

f

reques

ted s

ervic

es o

r dec

isio

ns

regard

ing

claim

s pay

men

ts. M

edic

are

and T

FL

hav

e

separa

te a

pp

eals

pro

cess

es. M

edic

are

rela

ted a

pp

eals

shou

ld b

e su

bm

itte

d t

o

Med

icare

. Y

ou s

hou

ld o

nly

subm

it a

pp

eals

to W

PS

if

TF

L i

s th

e pri

mary

pay

er.

21

(Am

eric

an S

am

oa

,* G

ua

m, th

e N

ort

her

n

Mari

an

a I

sla

nd

s, P

uer

to R

ico, a

nd t

he

U.S

. V

irgin

Isl

an

ds)

, you m

ust

pay

the

full

pri

ce o

f you

r pre

scri

pti

on u

p f

ront

and fi

le

a cl

aim

for

reim

bu

rsem

ent.

If y

ou l

ive

in t

he

Ph

ilip

pin

es, you a

re

requ

ired

to v

isit

a c

erti

fied

pharm

acy.

A

cert

ified

pharm

acy h

as b

een v

erifi

ed t

o

mee

t re

qu

ired

TO

P c

ontr

act

stand

ard

s

and i

s all

ow

ed t

o i

nvoic

e T

RIC

AR

E f

or

TR

ICA

RE

ben

efici

ary

cla

ims.

* C

urr

en

tly,

th

ere

are

no T

RIC

AR

E r

eta

il

net

work

ph

arm

aci

es i

n A

mer

ica

n S

am

oa

.

To fi

le a

cla

im:

1.

Dow

nlo

ad T

RIC

AR

E D

oD

/CH

AM

PU

S

Med

ica

l C

laim

Pa

tien

t’s

Req

ues

t fo

r

Med

ical P

aym

ent fo

rm (

DD

Form

26

42)

at w

ww

.tric

are

.mil

/cla

ims.

2.

Com

ple

te t

he

form

and a

ttac

h t

he

requ

ired

pap

erw

ork

as

des

crib

ed o

n

the

form

.

3.

Mail

the

form

and p

aper

work

to:

Expre

ss S

crip

ts, In

c.

TR

ICA

RE

Cla

ims

P.O

. B

ox 5

2132

Pho

enix

, A

Z 8

5082

Pre

scri

pti

on c

laim

s re

qu

ire

the

foll

ow

ing

info

rmat

ion f

or

each

dru

g:

• P

atie

nt’s

nam

e

• P

resc

ripti

on n

am

e, s

tren

gth

, d

ate

fill

ed,

day

s’ s

upply

, quan

tity

dis

pen

sed, a

nd p

rice

• N

atio

nal

Dru

g C

ode,

if

avail

able

• P

resc

ripti

on n

um

ber

• N

am

e and a

dd

ress

of

the

pharm

acy

• N

am

e and a

dd

ress

of

the

pre

scri

bin

g

physi

cian

Conta

ct E

xpre

ss S

crip

ts a

t 18

773

63

13

03

wit

h q

ues

tions

about fi

ling p

har

mac

y c

laim

s.

Ph

arm

acy C

laim

s A

pp

eals

If y

ou d

isag

ree

wit

h t

he

det

erm

inat

ion

on y

ou

r pharm

acy c

laim

(i.

e., i

f yo

ur

cla

im i

s d

enie

d),

you o

r you

r ap

poin

ted

repre

senta

tive

has

the

rig

ht

to r

eques

t a

reco

nsi

der

atio

n. T

he

reques

t (o

r a

ppea

l)

for

reco

nsi

der

atio

n m

ust

be

in w

riti

ng,

sig

ned

, and p

ost

mark

ed o

r re

ceiv

ed b

y

Expre

ss S

crip

ts w

ith

in 9

0 c

ale

nd

ar

day

s

from

the

dat

e of

the

dec

isio

n a

nd m

ust

incl

ude

a co

py o

f th

e cl

aim

dec

isio

n.

You

r si

gned

, w

ritt

en r

eques

t m

ust

sta

te t

he

spec

ific

mat

ter

you d

isag

ree

wit

h a

nd m

ust

be

sent to

the

foll

ow

ing a

dd

ress

no lat

er than

90 d

ays

from

the

dat

e of

the

noti

ce:

Expre

ss S

crip

ts, In

c.

P.O

. B

ox 6

09

03

Pho

enix

, A

Z 8

50820

903

Add

itio

nal do

cum

enta

tion i

n s

upport

of

the

appea

l m

ay b

e su

bm

itte

d;

how

ever

, bec

ause

the

reques

t fo

r re

consi

der

atio

n m

ust

be

post

mark

ed o

r re

ceiv

ed w

ith

in 9

0 c

ale

nd

ar

day

s of

the

dat

e of

the

dec

isio

n, do n

ot del

ay

the

reques

t fo

r re

consi

der

atio

n f

or

the

sake

of

add

itio

nal

do

cum

enta

tion. If

add

itio

nal

do

cum

enta

tion w

ill

be

subm

itte

d a

t a

late

r

dat

e, t

he

lett

er r

eques

ting r

econsi

der

atio

n

must

sta

te t

hat

add

itio

nal

do

cum

enta

tion

wil

l b

e su

bm

itte

d a

nd s

pec

ify t

he

exp

ecte

d

dat

e of

subm

issi

on. U

pon r

ecei

vin

g y

ou

r

reques

t, a

ll T

RIC

AR

E c

laim

s re

late

d t

o

the

enti

re c

ou

rse

of

trea

tmen

t are

rev

iew

ed.

SECTION 4

PHARMACY

12

Gett

ing

Care

Fin

din

g a

Provid

er

You m

ay r

ecei

ve

hea

lth c

are

ser

vic

es f

rom

Med

icar

epar

tici

pat

ing a

nd n

onpar

tici

pat

ing

pro

vid

ers,

as

wel

l as

fro

m p

rovid

ers

who

hav

e opte

d o

ut

of

Med

icare

. If

TR

ICA

RE

For

Lif

e (T

FL

) is

the

pri

mary

pay

er, you

must

vis

it T

RIC

AR

Ea

uth

ori

zed p

rovid

ers

and f

acil

itie

s. Y

ou w

ill

incu

r h

igher

out

of

po

cket

cost

s w

hen

you o

bta

in c

are

fro

m

opt

out

pro

vid

ers

or

Vet

erans

Aff

air

s (V

A)

pro

vid

ers.

Cost

s vary

acc

ord

ing t

o t

he

typ

e

of

pro

vid

er y

ou s

ee (

i.e., p

art

icip

ati

ng,

no

np

art

icip

ati

ng, opt

ou

t, V

A).

Med

icare

-Part

icip

ati

ng

Pro

vid

ers

Med

icare

part

icip

atin

g p

rovid

ers

agre

e to

acce

pt

the

Med

icare

appro

ved

am

ou

nt

as

pay

men

t in

fu

ll.

Med

icare

No

np

art

icip

ati

ng

Pro

vid

ers

Nonpart

icip

atin

g p

rovid

ers

do n

ot

acce

pt

the

Med

icare

appro

ved

am

ou

nt as

pay

men

t

in f

ull

. T

hey

may

charg

e up t

o 1

15 p

erce

nt

of

the

Med

icar

eap

pro

ved a

mount. T

FL

pay

s

up t

o t

he

115

per

cent

lim

itin

g c

harg

e.

Op

t-O

ut

Pro

vid

ers

Pro

vid

ers

who o

pt

out

of

Med

icare

ente

r

into

pri

vat

e co

ntr

acts

wit

h p

atie

nts

and a

re

not

all

ow

ed t

o b

ill

Med

icare

. T

her

efore

,

Med

icare

do

es n

ot

pay

for

hea

lth c

are

serv

ices

you r

ecei

ve

from

opt

out

pro

vid

ers.

When

you s

ee a

n o

pt

out

pro

vid

er, T

FL

pay

s th

e am

ou

nt

it w

ou

ld h

ave

paid

if

Med

icar

e had

pro

cess

ed the

clai

m (norm

all

y

20 p

erce

nt

of

the

all

ow

able

ch

arg

e) a

nd

you a

re r

esponsi

ble

for

pay

ing the

rem

ainder

of

the

bil

led c

harg

es. In

cas

es w

her

e ac

cess

to m

edic

al c

are

is

lim

ited

(i.

e., u

nder

serv

ed

are

as)

, T

FL

may

waiv

e th

e se

condp

ayer

stat

us

for

Med

icare

opt

out

pro

vid

ers

and

pay

the

claim

as

the

pri

mary

pay

er.

Vete

ran

s A

ffair

s P

rovid

ers

Med

icare

can

not

pay

for

serv

ices

rec

eived

from

VA

. T

her

efore

, T

RIC

AR

E i

s th

e

pri

mary

pay

er f

or

VA

cla

ims

and y

ou w

ill

be

resp

onsi

ble

for

the

TR

ICA

RE

an

nual

ded

uct

ible

and c

ost

share

s. A

lter

nat

ivel

y,

you m

ay c

hoose

to u

se y

ou

r V

A b

enefi

t.

Mil

itary

Tre

atm

en

t Facil

itie

s

A m

ilit

ary

tre

atm

ent

faci

lity

(M

TF

) is

a

mil

itary

hosp

ital

or

clin

ic u

suall

y l

oca

ted

on o

r nea

r a

mil

itary

bas

e. Y

ou m

ay r

ecei

ve

care

at

an M

TF

on a

spac

eav

ail

able

bas

is.

See

Fig

ure

2.1

for

MT

F a

ppoin

tmen

t

pri

ori

ties

.

MT

F A

pp

oin

tmen

t P

rio

riti

es

Fig

ure

2.1

1A

ctiv

e duty

ser

vic

e m

emb

ers

2A

ctiv

e duty

fam

ily

mem

ber

s (A

DF

Ms)

enro

lled

in

TR

ICA

RE

Pri

me

3R

etir

ed s

erv

ice

mem

ber

s, t

hei

r fa

mil

ies,

and

all

oth

ers

enro

lled

in

TR

ICA

RE

Pri

me

or

TR

ICA

RE

Plu

s

4A

DF

Ms

not en

roll

ed in T

RIC

AR

E P

rim

e

TR

ICA

RE

Res

erve

Sel

ect

mem

ber

s and

thei

r fa

mil

ies

5R

etir

ed s

erv

ice

mem

ber

s, t

hei

r fa

mil

ies,

TR

ICA

RE

Ret

ired

Res

erve

mem

ber

s and

thei

r fa

mil

ies,

and

all

oth

ers

not

enro

lled

in T

RIC

AR

E P

rim

e

13

Overs

ea

s P

rovid

ers

Wit

h T

FL

over

seas

, you m

ay g

ener

all

y u

se

any h

ost

nat

ion p

rovid

er a

nd r

ecei

ve

care

at M

TF

s on a

spac

eav

ail

able

bas

is, u

nle

ss

reg

ion

or

cou

ntr

ys

pec

ific

requ

irem

ents

apply

. W

hen

see

kin

g c

are

fro

m a

host

nat

ion p

rovid

er, you s

hou

ld b

e pre

pare

d

to p

ay u

p f

ront

for

serv

ices

and s

ubm

it a

clai

m t

o t

he

TR

ICA

RE

Over

seas

Pro

gra

m

(TO

P)

claim

s pro

cess

or.

For

more

info

rmat

ion a

bout

get

ting c

are

over

seas

,

call

you

r T

OP

Reg

ional

Call

Cen

ter

or

vis

it w

ww

.tric

are

over

sea

s.co

m.

Em

ergency C

are

TR

ICA

RE

defi

nes

an e

mer

gen

cy a

s a

med

ical

, m

ater

nit

y, o

r psy

chia

tric

condit

ion

that

wou

ld l

ead a

“pru

den

t la

yp

erso

n”

(som

eone

wit

h a

vera

ge

know

ledge

of

hea

lth

an

d m

edic

ine)

to b

elie

ve

that

a s

erio

us

med

ical

condit

ion e

xis

ts; th

at t

he

abse

nce

of

imm

edia

te m

edic

al a

tten

tion w

ould

res

ult

in

a th

reat

to l

ife,

lim

b, or

sight;

when

a p

erso

n

has

sev

ere,

pain

ful

sym

pto

ms

requ

irin

g

imm

edia

te a

tten

tion t

o r

elie

ve

suff

erin

g;

or

when

a p

erso

n i

s at

im

med

iate

ris

k t

o s

elf

or

oth

ers.

The

TR

ICA

RE

hea

lth c

are

ben

efit

cover

s ad

junct

ive

den

tal

care

(i.

e., d

enta

l

care

th

at

is m

edic

all

y n

eces

sary

to t

rea

t

a c

ove

red m

edic

al—

not den

tal—

condit

ion)

.

The

TR

ICA

RE

hea

lth c

are

ben

efit

do

es

not

cover

nona

dju

nct

ive

den

tal

care

,

wh

ich r

efer

s to

any r

outi

ne,

pre

ven

tive,

rest

ora

tive,

pro

stho

donti

c, p

erio

donti

c,

or

emer

gen

cy d

enta

l ca

re t

hat

is

not

rela

ted t

o a

med

ical

cond

itio

n. E

lig

ible

TR

ICA

RE

ben

efici

ari

es m

ay r

ecei

ve

nona

dju

nct

ive

den

tal

serv

ices

if

enro

lled

in t

he

TR

ICA

RE

Den

tal

Pro

gra

m o

r th

e

TR

ICA

RE

Ret

iree

Den

tal

Pro

gra

m.

If y

ou n

eed e

mer

gen

cy c

are

, ca

ll 9

11 o

r go

to t

he

nea

rest

em

ergen

cy r

oom

. M

ake

sure

you p

rese

nt yo

ur

Med

icare

card

so t

hat

you

r

claim

is

file

d w

ith M

edic

are

.

If t

ravel

ing o

r li

vin

g o

ver

seas

, fi

rst

atte

mpt

to s

eek c

are

fro

m t

he

nea

rest

MT

F. If

an

MT

F i

s not

avail

able

, se

ek c

are

fro

m t

he

nea

rest

em

ergen

cy r

oom

. Y

ou c

an c

onta

ct

the

TO

P R

egio

nal

Call

Cen

ter

for

you

r

reg

ion f

or

assi

stance

in fi

nd

ing a

host

nat

ion p

rovid

er.

Note

: M

ost

den

tal

cond

itio

ns

that

may

be

consi

der

ed e

mer

gen

cies

are

not

cover

ed

under

Med

icare

or

TF

L.

Urgent

Care

Urg

ent

care

ser

vic

es a

re m

edic

all

y

nec

essa

ry s

ervic

es r

equ

ired

for

an i

llnes

s

or

inju

ry t

hat

wou

ld n

ot

resu

lt i

n f

urt

her

SECTION 2

GETTING CARE

20

ww

w.p

ec.h

a.o

sd.m

il/f

orm

s_cr

iter

ia.p

hp

for

form

s and m

edic

al

nec

essi

ty c

rite

ria.

For

info

rmat

ion o

n h

ow

to s

ave

money

and

make

the

most

of

you

r pharm

acy b

enefi

t,

vis

it w

ww

.tric

are

.mil

/ph

arm

acy

or

ww

w.e

xp

ress

scr

ipts

.com

/TR

ICA

RE

.

Sp

ecia

lty M

ed

icati

on

C

are

Man

ag

em

en

t

Spec

ialt

y m

edic

atio

ns

are

usu

ally

hig

hc

ost

;

self

adm

inis

tere

d; in

ject

able

, ora

l, o

r in

fuse

d

dru

gs

that

tre

at s

erio

us

chro

nic

cond

itio

ns

(e.g

., m

ult

iple

scl

erosi

s, r

heu

mato

id a

rthri

tis,

hep

ati

tis

C).

Thes

e d

rugs

typic

all

y r

equ

ire

spec

ial

stora

ge

and h

and

ling a

nd a

re n

ot

read

ily a

vail

able

at

you

r lo

cal

pharm

acy.

Sp

ecia

lty m

edic

atio

ns

may

als

o h

ave

side

effe

cts

that

req

uir

e pharm

acis

t and

/or

nu

rse

mon

itori

ng.

The

Sp

ecia

lty M

edic

atio

n C

are

Manag

emen

t pro

gra

m i

s st

ruct

ure

d t

o

impro

ve

you

r hea

lth t

hro

ug

h c

onti

nuous

hea

lth e

valu

atio

n, ongoin

g m

on

itori

ng,

asse

ssm

ent

of

educa

tional

nee

ds,

and

med

icat

ionu

se m

anag

emen

t. T

his

pro

gra

m p

rovid

es:

• A

cces

s to

pro

acti

ve,

cli

nic

all

y b

ased

serv

ices

for

spec

ific

dis

ease

s and i

s

des

igned

to h

elp y

ou g

et t

he

most

ben

efit

from

you

r m

edic

atio

n

• M

onth

ly r

efill

rem

inder

call

s

• S

ched

ule

d d

eliv

erie

s to

spec

ified

loca

tions

• S

pec

ialt

y c

onsu

ltat

ion w

ith a

nu

rse

or

pharm

acis

t at

any p

oin

t du

ring

you

r th

erap

y

Thes

e se

rvic

es a

re p

rov

ided

to

you

at

no a

dd

itio

nal

cost

when

you r

ecei

ve

you

r

med

icat

ions

thro

ug

h T

RIC

AR

E P

harm

acy

Hom

e D

eliv

ery.

Part

icip

atio

n i

s volu

nta

ry.

If y

ou o

r you

r pro

vid

er o

rder

s a

spec

ialt

y

med

icat

ion f

rom

TR

ICA

RE

Pharm

acy

Hom

e D

eliv

ery,

Expre

ss S

crip

ts s

ends

you

add

itio

nal

info

rmat

ion a

bout

the

Sp

ecia

lty

Med

icat

ion C

are

Man

agem

ent pro

gra

m a

nd

how

to g

et s

tart

ed.

Usi

ng T

RIC

AR

E P

harm

acy H

om

e D

eliv

ery

to fi

ll s

pec

ialt

y m

edic

atio

n p

resc

ripti

ons

pro

vid

es y

ou w

ith a

cces

s to

the

Sp

ecia

lty

Med

icat

ion C

are

Manag

emen

t pro

gra

m

ben

efits

pre

vio

usl

y d

escr

ibed

. W

ith s

pec

ific

mail

ing i

nst

ruct

ions

from

you o

r you

r

pro

vid

er, T

RIC

AR

E P

harm

acy H

om

e

Del

iver

y s

hip

s you

r sp

ecia

lty m

edic

atio

n

to y

ou

r hom

e. F

or

you

r co

nven

ience

and

safe

ty, T

RIC

AR

E P

har

mac

y H

om

e D

eliv

ery

conta

cts

you t

o a

rrange

del

iver

y b

efore

the

med

icat

ion i

s sh

ipp

ed.

Note

: S

om

e sp

ecia

lty m

edic

atio

ns

may

not

be

avail

able

th

roug

h T

RIC

AR

E P

harm

acy

Hom

e D

eliv

ery b

ecau

se t

he

med

icat

ion’

s

manu

fact

ure

r li

mit

s th

e d

rug’s

dis

trib

uti

on

to s

pec

ific

pharm

acie

s. I

f you s

ubm

it a

pre

scri

pti

on f

or

a li

mit

edd

istr

ibuti

on

med

icat

ion, T

RIC

AR

E P

harm

acy H

om

e

Del

iver

y e

ither

forw

ard

s you

r pre

scri

pti

on

to a

pharm

acy o

f you

r ch

oic

e th

at c

an fi

ll

it o

r pro

vid

es y

ou w

ith i

nst

ruct

ions

about

wher

e to

sen

d t

he

pre

scri

pti

on t

o h

ave

it fi

lled

.

Pharm

acy C

laim

s

You d

o n

ot

nee

d t

o fi

le p

harm

acy c

laim

s

for

pre

scri

pti

ons

fill

ed a

t M

TF

pharm

acie

s,

thro

ug

h T

RIC

AR

E P

harm

acy H

om

e

Del

iver

y, o

r at

TR

ICA

RE

ret

ail

net

work

pharm

acie

s. H

ow

ever

, if

you fi

ll a

pre

scri

pti

on a

t a

nonn

etw

ork

pharm

acy

in t

he

Un

ited

Sta

tes

or

U.S

. te

rrit

ori

es

19

Pharm

acy P

olicy

Qu

an

tity

Lim

its

TR

ICA

RE

has

est

abli

shed

quanti

ty l

imit

s

on c

erta

in m

edic

atio

ns,

wh

ich m

eans

the

Dep

art

men

t of

Def

ense

(D

oD

) pay

s fo

r a

spec

ified

, li

mit

ed a

mou

nt

of

med

icat

ion

each

tim

e you fi

ll a

pre

scri

pti

on. Q

uanti

ty

lim

its

are

oft

en a

ppli

ed to

ensu

re m

edic

atio

ns

are

safe

ly a

nd a

ppro

pri

atel

y u

sed.

Exce

pti

ons

to e

stab

lish

ed q

uanti

ty l

imit

s

may

be

mad

e if

the

pre

scri

bin

g p

rovid

er

can just

ify m

edic

al n

eces

sity

, or,

in c

ases

of

nat

ura

l dis

aste

rs, a

s ap

pro

ved b

y T

RIC

AR

E.

Pri

or

Au

tho

rizati

on

Som

e d

rugs

requ

ire

pri

or

auth

ori

zati

on

from

Expre

ss S

crip

ts.

Med

icat

ion

s

requ

irin

g p

rior

auth

ori

zati

on m

ay i

ncl

ude,

but

are

not

lim

ited

to,

pre

scri

pti

on

dru

gs

speci

fied

by

the

DoD

Pharm

acy

and

Ther

apeu

tics

(P&

T)

Com

mit

tee,

bra

nd

nam

e m

edic

atio

ns

wit

h g

ener

ic e

qu

ivale

nts

,

med

icat

ion

s w

ith

age

lim

itat

ion

s, a

nd

med

icat

ion

s pre

scri

bed

for

qu

anti

ties

exce

ed

ing

norm

al

lim

its.

If

you

do

not

hav

e In

tern

et a

cces

s, c

all

18

773

63

13

03

to i

nqu

ire

about

a sp

ecifi

c d

rug.

Gen

eri

c D

rug

-Use P

oli

cy

Gen

eric

dru

gs

are

med

icat

ions

appro

ved

by t

he

U.S

. F

oo

d a

nd D

rug A

dm

inis

trat

ion

and a

re c

lin

ical

ly e

quiv

alen

t to

bra

ndn

ame

med

icat

ions.

Gen

eric

dru

gs

pro

vid

e th

e sa

me

safe

, ef

fect

ive

trea

tmen

t as

bra

ndn

am

e

dru

gs.

It

is D

oD

poli

cy t

o u

se g

ener

ic

med

icat

ions

inst

ead o

f bra

ndn

am

e

med

icat

ions

when

ever

poss

ible

. A

bra

nd

nam

e d

rug w

ith a

gen

eric

equ

ivale

nt

may

be

dis

pen

sed o

nly

aft

er t

he

pre

scri

bin

g

physi

cian c

om

ple

tes

a cl

inic

al

asse

ssm

ent

indic

atin

g the

bra

ndn

ame

dru

g is

med

ical

ly

nec

essa

ry a

nd a

fter

Expre

ss S

crip

ts

gra

nts

appro

val.

Pre

scri

ber

s m

ay c

all

18

66

68

44

48

8 t

o s

ubm

it a

req

ues

t

for

a bra

ndn

am

e d

rug t

o b

e d

isp

ense

d

inst

ead o

f a

gen

eric

, or

a co

mple

ted f

orm

may

be

faxed

to:

18

66

68

44

477.

The

Bra

nd o

ver

Gen

eric

Pri

or

Au

thori

zati

on

Req

ues

t F

orm

may

be

fou

nd a

t

ww

w.p

ec.h

a.o

sd.m

il/f

orm

s_cr

iter

ia.p

hp

.

If a

gen

eric

equ

ivale

nt

dru

g d

oes

not

exis

t,

the

bra

ndn

am

e d

rug i

s d

isp

ense

d a

t th

e

bra

ndn

am

e co

pay

men

t.

If y

ou fi

ll a

pre

scri

pti

on w

ith a

bra

ndn

ame

dru

g t

hat

is

not

consi

der

ed m

edic

all

y

nec

essa

ry a

nd w

hen

a g

ener

ic e

qu

ivale

nt

is a

vail

able

, you a

re r

esponsi

ble

for

pay

ing

the

enti

re c

ost

of

the

pre

scri

pti

on.

No

n-F

orm

ula

ry D

rug

s

The

DoD

P&

T C

om

mit

tee

may

rec

om

men

d

to t

he

dir

ecto

r of

TR

ICA

RE

Manag

emen

t

Act

ivit

y t

hat

cer

tain

dru

gs

be

pla

ced i

n

the

thir

d, “n

onf

orm

ula

ry”

tier

. T

hes

e

med

icat

ions

incl

ude

any d

rug i

n a

ther

apeu

tic

clas

s det

erm

ined

to b

e le

ss

rela

tivel

y c

lin

icall

y e

ffec

tive

or

cost

effe

ctiv

e th

an o

ther

dru

gs

in t

he

sam

e

clas

s. F

or

an a

dd

itio

nal

cost

, th

irdt

ier

dru

gs

are

avail

able

th

roug

h T

RIC

AR

E

Pharm

acy H

om

e D

eliv

ery o

r re

tail

net

work

pharm

acie

s. Y

ou m

ay b

e ab

le t

o fi

ll n

on

form

ula

ry p

resc

ripti

ons

at f

orm

ula

ry

cost

s if

you

r pro

vid

er c

an e

stab

lish

med

ical

nec

essi

ty b

y c

om

ple

ting a

nd

subm

itti

ng t

he

appro

pri

ate

TR

ICA

RE

pharm

acy m

edic

al

nec

essi

ty f

orm

for

the

nonf

orm

ula

ry m

edic

atio

n. C

all

Expre

ss S

crip

ts a

t 18

773

63

13

03 o

r vis

it

SECTION 4

PHARMACY

14

dis

abil

ity o

r dea

th if

not tr

eate

d im

med

iate

ly,

but

do

es r

equ

ire

pro

fess

ional

atte

nti

on

wit

hin

24 h

ou

rs. Y

ou c

ou

ld r

equ

ire

urg

ent

care

for

cond

itio

ns

such

as

a sp

rain

, so

re

thro

at, or

risi

ng t

emp

erat

ure

, as

eac

h o

f

thes

e has

the

pote

nti

al

to d

evel

op i

nto

an

emer

gen

cy i

f tr

eatm

ent

is d

elay

ed l

onger

than 2

4 h

ou

rs.

Behavio

ral H

ealt

h C

are

Med

icare

hel

ps

cover

vis

its

wit

h t

he

foll

ow

ing t

yp

es o

f hea

lth c

are

pro

vid

ers:

• A

psy

chia

tris

t or

oth

er d

oct

or

• C

lin

ical

psy

cholo

gis

t

• C

lin

ical

soci

al

work

er

• C

lin

ical

nu

rse

spec

iali

st

• N

urs

e pra

ctit

ioner

• P

hysi

cian’

s as

sist

ant

Med

icare

on

ly c

over

s th

ese

vis

its

when

they

are

pro

vid

ed b

y h

ealt

h c

are

pro

vid

ers

who a

ccep

t M

edic

are

pay

men

t. T

o p

ay e

ven

less

, you s

hou

ld a

lso a

sk y

ou

r hea

lth c

are

pro

vid

ers

if t

hey

acc

ept

assi

gn

men

t, w

hic

h

mea

ns

they

acc

ept

the

Med

icare

appro

ved

am

ou

nt

as p

aym

ent

in f

ull

, b

efore

you

sched

ule

an a

ppoin

tmen

t.

For

more

in

form

atio

n o

n M

edic

are

’s

beh

avio

ral

hea

lth c

are

cover

age,

vis

it

ww

w.m

edic

are

.gov.

Prio

r A

uth

oriz

ati

on f

or C

are

When

TF

L b

ecom

es t

he

pri

mary

pay

er

(e.g

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f yo

ur

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ben

efits

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exh

au

sted

), T

RIC

AR

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rior

auth

ori

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on

requ

irem

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apply

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or

auth

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w o

f th

e

reques

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ealt

h c

are

ser

vic

e to

det

erm

ine

if it

is m

edic

all

y n

eces

sary

at

the

reques

ted

level

of

care

. If

you h

ave

an a

uth

ori

zati

on

from

a T

RIC

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E r

egio

nal

contr

act

or

(Hea

lth

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Fed

era

l S

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ma

na

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c.) t

hat

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on

you

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vic

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wil

l honor

those

auth

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and n

o T

FL

auth

ori

zati

on i

s re

qu

ired

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he

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Lif

e A

uth

ori

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equ

est

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WP

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eb s

ite.

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vid

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shou

ld fi

ll o

ut

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TR

ICA

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equ

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form

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it i

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fax n

um

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pro

vid

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n

the

top r

ight

corn

er o

f th

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rm.

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ou h

ave

ques

tions

about

auth

ori

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on

requ

irem

ents

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nta

ct W

PS

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foll

ow

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ervic

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equ

ire

pri

or

auth

ori

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on:

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dju

nct

ive

den

tal

serv

ices

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ll o

utp

atie

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beh

avio

ral

hea

lth c

are

aft

er t

he

firs

t ei

ght

sess

ions

in a

fisc

al

yea

r (O

ctober

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tem

ber

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from

an a

uth

ori

zed

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dep

enden

t b

ehav

iora

l

hea

lth p

rovid

er

• D

enta

l anes

thes

ia a

nd i

nst

ituti

onal

care

• H

osp

ice

care

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pat

ient

beh

avio

ral

hea

lth c

are

ser

vic

es

• O

rgan a

nd s

tem

cel

l tr

ansp

lants

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art

ial

hosp

itali

zati

on

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sych

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sis

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his

lis

t is

not

all

incl

usi

ve.

15

TR

ICA

RE F

or

Lif

e C

overa

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TR

ICA

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edic

al Covera

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TR

ICA

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FL

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edic

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pro

ven

, m

edic

all

y n

eces

sary

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appro

pri

ate

care

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FL

has

sp

ecia

l ru

les

and

lim

itat

ions

for

cert

ain

ty

pes

of

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som

e ty

pes

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ICA

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poli

cies

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ver

y s

pec

ific

about

wh

ich s

ervic

es a

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over

ed a

nd w

hic

h a

re

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n y

ou

r b

est

inte

rest

to t

ake

an

acti

ve

role

in v

erif

yin

g c

over

age.

Note

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edic

are

als

o h

as l

imit

s on t

he

am

ou

nt

of

care

it

cover

s and

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som

e

case

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FL

may

cover

thes

e hea

lth c

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serv

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aft

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ou

r M

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efits

hav

e

bee

n e

xhau

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To d

eter

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vis

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sit

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ww

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in t

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sect

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or

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info

rmat

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n y

ou

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of

po

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cost

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Exam

ple

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serv

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that

are

gen

erall

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not re

imbu

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ither

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gra

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cupu

nct

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xp

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enta

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inves

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ices

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ost

ca

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d y

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63

88

371.

SECTION 2

GETTING CARE

SECTION 3

TRICARE FOR LIFE COVERAGE

18

and t

he

pre

scri

pti

on m

ust

be

from

a

U.S

.li

cense

d p

rovid

er.

If y

ou h

ave

pre

scri

pti

on d

rug c

over

age

thro

ug

h o

ther

hea

lth i

nsu

rance

(O

HI)

,

you c

an u

se T

RIC

AR

E P

harm

acy H

om

e

Del

iver

y o

nly

if

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med

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ion i

s not

cover

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nder

you

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or

if y

ou e

xce

ed

the

OH

I’s

cover

age

lim

it. R

egis

ter

for

TR

ICA

RE

Pharm

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om

e D

eliv

ery

usi

ng a

ny o

f th

e opti

ons

in F

igu

re 4

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Mem

ber

Ch

oic

e C

en

ter

The

Mem

ber

Choic

e C

ente

r m

akes

it

easy

to r

educe

you

r out

of

po

cket

cost

s

by t

ransf

erri

ng y

ou

r cu

rren

t m

ain

tenance

med

icat

ion p

resc

ripti

ons

to T

RIC

AR

E

Pharm

acy H

om

e D

eliv

ery.

Note

: To u

se the

Mem

ber

Choic

e C

ente

r, y

ou

must

hav

e a

main

tenance

pre

scri

pti

on f

rom

a re

tail

pharm

acy

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F.

The

Mem

ber

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ente

r co

nta

cts

you

r pro

vid

er to g

et

new

wri

tten

pre

scri

pti

ons

for

hom

e del

iver

y.

TR

ICA

RE R

eta

il N

etw

ork

Ph

arm

acie

s

Anoth

er o

pti

on f

or

fill

ing y

ou

r pre

scri

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is t

hro

ug

h T

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AR

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etail

net

work

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acie

s. Y

ou m

ay fi

ll p

resc

ripti

ons

(one

cop

aym

ent

per

30

da

y su

pply

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hen

you

pre

sent

you

r w

ritt

en p

resc

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on a

nd

unif

orm

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ervic

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D c

ard to

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phar

mac

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pti

on a

llow

s you t

o fi

ll p

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ripti

ons

at T

RIC

AR

E n

etw

ork

pharm

acie

s w

ithout

subm

itti

ng c

laim

s. Y

ou h

ave

acce

ss t

o

appro

xim

atel

y 5

6,0

00 r

etail

net

work

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acie

s in

the

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ited

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tes

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U.S

. te

rrit

ori

es o

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uam

, th

e N

ort

her

n

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ana

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nds,

Puer

to R

ico, and t

he

U.S

. V

irg

in I

slands.

TR

ICA

RE

ret

ail

net

work

pharm

acie

s are

on

ly l

oca

ted

in t

he

Un

ited

Sta

tes

and U

.S. te

rrit

ori

es.

Cu

rren

tly,

ther

e are

no T

RIC

AR

E r

etail

net

work

pharm

acie

s in

Am

eric

an S

am

oa.

Vis

it w

ww

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s

When

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ork

pharm

acie

s,

you p

ay t

he

full

pri

ce o

f you

r m

edic

atio

n

up f

ront and fi

le a

cla

im for

reim

bu

rsem

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requ

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mad

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ail

s ab

out

fili

ng a

cla

im, se

e

the

Cla

ims

sect

ion o

f th

is h

andbook.

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ICA

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Ph

arm

acy

Hom

e D

eliv

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Reg

istr

ati

on

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igu

re 4

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ICA

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for

fill

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ou

r pre

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pti

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ICA

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ven

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o fi

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a pre

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ou n

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pre

scri

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nd

a vali

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den

tifi

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onn

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ork

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ervic

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AR

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or

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e

reco

mm

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ll a

ll o

f you

r

pre

scri

pti

ons

bef

ore

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vel

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ver

seas

.

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erta

in o

vers

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tions,

reg

ions

pec

ific

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quir

emen

ts m

ay r

equir

e

usi

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tifi

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harm

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For

more

in

form

atio

n, co

nta

ct y

ou

r T

RIC

AR

E

Over

seas

Pro

gra

m (

TO

P)

Reg

ional

Call

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ter or vis

it w

ww

.tric

are

over

sea

s.co

m.

Note

: Y

ou d

o n

ot

nee

d a

Med

icare

Part

D

pre

scri

pti

on

dru

g p

lan

to

keep

you

r

TR

ICA

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pre

scri

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on d

rug c

over

age.

Filling P

rescrip

tions

Milit

ary

Tre

atm

en

t Faci

lity

Ph

arm

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TF

pharm

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e le

ast

exp

ensi

ve

opti

on f

or

fill

ing p

resc

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an

MT

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you m

ay r

ecei

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up t

o

a 9

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ay s

upply

of

most

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at

no c

ost

. M

ost

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harm

acie

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cept

pre

scri

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tten

by b

oth

civ

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n a

nd

mil

itary

pro

vid

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reg

ard

less

of

whet

her

or

not

you a

re e

nro

lled

at

the

MT

F.

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orm

ula

ry m

edic

atio

ns

are

gen

erall

y

not av

ail

able

at M

TF

pharm

acie

s. T

o c

hec

k

the

avail

abil

ity o

f a

part

icu

lar

dru

g, co

nta

ct

the

nea

rest

MT

F p

harm

acy.

TR

ICA

RE P

harm

acy H

om

e D

eli

very

TR

ICA

RE

Pharm

acy H

om

e D

eliv

ery i

s

you

r le

ast

exp

ensi

ve

opti

on w

hen

not

usi

ng

an M

TF

pharm

acy.

Ther

e is

no c

ost

for

hom

e del

iver

y f

or

AD

SM

s. F

or

all

oth

er

ben

efici

ari

es, th

ere

is n

o c

ost

to r

ecei

ve

up

to a

90

day

supply

of

gen

eric

med

icat

ions.

Copay

men

ts a

pply

for

bra

ndn

am

e and

nonf

orm

ula

ry m

edic

atio

ns.

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itio

nall

y,

pre

scri

pti

ons

are

del

iver

ed t

o y

ou w

ith f

ree

stand

ard

sh

ippin

g, and r

efill

s ca

n b

e ea

sily

ord

ered

on

line,

by p

hone,

or

by m

ail

.

TR

ICA

RE

Pharm

acy H

om

e D

eliv

ery

als

o p

rovid

es y

ou w

ith r

efill

rem

inder

s,

conven

ient

noti

fica

tions

about

you

r ord

er

stat

us,

and a

ssis

tance

wit

h r

enew

ing

expir

ed p

resc

ripti

ons.

If

you h

ave

ques

tions

about

you

r pre

scri

pti

ons,

pharm

acis

ts a

re

avail

able

24 h

ou

rs a

day

, se

ven

day

s a

wee

k t

o t

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fiden

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ith y

ou.

For

fast

er p

roce

ssin

g o

f you

r m

ail

ord

er

pre

scri

pti

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reg

iste

r b

efore

pla

cing y

ou

r

firs

t ord

er. O

nce

you a

re r

egis

tere

d, you

r

pro

vid

er c

an fax

or

call

in y

our

pre

scri

pti

ons.

Expre

ss S

crip

ts, I

nc.

(E

xpre

ss S

crip

ts)

sends

you

r m

edic

atio

ns

dir

ectl

y t

o y

ou

r hom

e

wit

hin

about

14 d

ays

of

rece

ivin

g y

ou

r

pre

scri

pti

on.

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: O

ver

seas

ben

efici

ari

es m

ust

hav

e

an A

PO

/FP

O o

r em

bas

sy a

dd

ress

to u

se

TR

ICA

RE

Pharm

acy H

om

e D

eliv

ery,

SECTION 3

TRICARE FOR LIFE COVERAGE

SECTION 4

PHARMACY

16

TR

ICA

RE R

eti

ree D

en

tal

Pro

gra

m

The

TR

DP

is

avail

able

to r

etir

ed s

ervic

e

mem

ber

s an

d thei

r el

igib

le f

amil

y m

ember

s,

incl

ud

ing r

etir

ed N

atio

nal

Guard

and

Res

erve

mem

ber

s w

ho a

re e

nti

tled

to

reti

rem

ent

pay

but

do n

ot

beg

in r

ecei

vin

g

it u

nti

l ag

e 60, t

hei

r el

igib

le fam

ily m

ember

s,

cert

ain

su

rviv

ing f

am

ily m

emb

ers

of

dec

ease

d a

ctiv

e duty

sponso

rs, and M

edal

of

Honor

reci

pie

nts

and t

hei

r im

med

iate

fam

ily m

emb

ers

and s

urv

ivors

. F

or

info

rmat

ion a

bout

the

TR

DP,

incl

ud

ing

poss

ible

res

tric

tions,

vis

it t

he

TR

DP

Web

site

at

ww

w.t

rdp

.org

or

call

Del

ta D

enta

l®

of

Cali

forn

ia t

oll

fre

e at

18

88

83

88

737.

Frequentl

y A

sked Q

uesti

ons:

TR

ICA

RE F

or L

ife C

overa

ge

Does

TF

L c

over

lon

gt

erm

ca

re?

No. L

ongt

erm

care

(or

cust

odia

l ca

re)

is n

ot

a co

ver

ed b

enefi

t. H

ow

ever

, you

may

quali

fy t

o p

urc

has

e lo

ngt

erm

care

insu

rance

th

roug

h c

om

mer

cial

insu

rance

pro

gra

ms

or

thro

ug

h t

he

Fed

eral

Long

Ter

m C

are

Insu

rance

Pro

gra

m. F

or

more

info

rmat

ion a

bout

the

Fed

eral

Long

Ter

m C

are

Insu

rance

Pro

gra

m, vis

it

ww

w.o

pm

.gov/i

nsu

re/l

tc o

r ca

ll

18

00

582

3337.

Does

TR

ICA

RE

cover

sk

ille

d

nu

rsin

g c

are

?

TF

L c

over

s re

asonab

le a

nd n

eces

sary

sk

ille

d

nu

rsin

g c

are

and r

ehab

ilit

ativ

e th

erap

ies,

incl

udin

g s

emip

riva

te r

oom

s; r

egula

r nurs

ing

serv

ices

; m

eals

(in

clu

din

g s

pec

ial

die

ts);

physi

cal,

occ

upat

ional,

and s

pee

ch ther

apy;

dru

gs

furn

ished

by th

e fa

cility

; and n

eces

sary

med

ical

suppli

es a

nd a

ppli

ance

s. S

kil

led

nu

rsin

g c

are

is

typic

all

y p

rovid

ed i

n a

skil

led n

urs

ing f

acil

ity (

SN

F).

For

TF

L a

nd M

edic

are

to c

over

SN

F

adm

issi

on, you m

ust

hav

e had

a m

edic

al

cond

itio

n t

hat

was

tre

ated

in a

hosp

ital

for

at l

east

th

ree

conse

cuti

ve

day

s, a

nd y

ou

must

be

adm

itte

d t

o a

Med

icare

cer

tifi

ed,

TR

ICA

RE

par

tici

pat

ing S

NF

within

30 d

ays

of

dis

charg

e fr

om

the

hosp

ital

(wit

h s

om

e

exce

pti

on

s fo

r m

edic

al

rea

son

s). Y

ou

r

do

ctor’

s pla

n o

f ca

re m

ust

dem

onst

rate

you

r nee

d f

or

skil

led n

urs

ing s

ervic

es.

Note

: T

FL

is

the

pri

mary

pay

er f

or

SN

F

care

bey

ond M

edic

are

’s 1

00

day

lim

it a

s

long a

s th

e pat

ient

conti

nues

to r

equ

ire

skil

led n

urs

ing s

ervic

es a

nd n

o o

ther

hea

lth i

nsu

rance

is

involv

ed. S

NF

care

requ

ires

pri

or

auth

ori

zati

on o

n d

ay 1

01,

when

TR

ICA

RE

is

the

pri

mary

pay

er.

TF

L c

over

s an u

nli

mit

ed n

um

ber

of

day

s

as m

edic

all

y n

eces

sary

. S

NF

care

is

not

cover

ed o

uts

ide

the

Un

ited

Sta

tes

and

U.S

. te

rrit

ori

es.

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